Mark Klimek Nclexgold Lecture Notes EDIT

Mark Klimek NCLEX GOLD
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NOTHING IS IMPOSSIBLE- THE WORD
ITSELF SAYS “I’M POSSIBLE”
NCLEX TIPS
Do not read into the question- never assume anything that has not been
specifically mentioned (in the question) and do not add extra meaning or
history to the question—do not make up a story to validate choosing an
answer
NCLEX land is set at Utopia General Hospital- you have all the time, all the
resources, and all the staff you need!
Least invasive to most invasive – least restrictive to most restrictive
(restraints are rarely a good choice)
Avoid using absolutes- always, never, must, etc.
Assess the client first before implementing a treatment or action—if there’s a
choice that pertains to assessment of the patient—it is usually the answer –
assess unless in distress
Priority goes to assessments and answers that deal with the patient (patient-
focused) directly and not with machines/monitors/equipment (unless the
question is specifically asking about them)
o Ex: Auscultate fetal heart rate before checking the monitor
If it is the FIRST time doing something for or with the patient (such as vital
signs upon admission to the floor/unit, or when a transfer is involved), the
NURSE must complete the assessment- including vital signs
If patient is an adult, answers with family options can be ruled out (unless
patient is not competent to make own decisions)
In emergency situations (mass casualty), patients with greater chance to live
are treated first
If you are asked about the FIRST action you would take in a
prioritization/discrimination question think: “If I can only do one action,
and then I must go home, what will the outcome be?”
Therapeutic communication- reflect feelings and provide correct
information
Do not ask “why” questions (or yes/no) and do not say “I understand”
An answer that delays care or treatment is usually wrong (Ex: reassess in 15
minutes, monitor the patient for a continuation of symptoms)
When determining interventions to enhance a client’s wellness, consider
options that promote healthy nutrition, regular exercise, proper weight
maintenance, proper rest, and avoidance of harmful chemicals (nicotine) and
risk-taking behaviors (not wearing a seat belt)
If two of the answer choices are the exact opposite, one is probably the
answer (ie. bradycardia, tachycardia)
If two or three answers are similar, none are correct (*be careful—
sometimes answers may seem similar but in fact are saying something
different)
Always look for the UMBRELLA option—one that is a broad universal
statement and usually contains the concepts of the other options with it—
often the correct answer

If you have never heard of an answer—do not eliminate it—work around it…if
you can safely eliminate all other answers, that is your answer—if you are down
to two answers and you know one answer is right, go with what you know
Prioritize actual problems over potential problems
DO NOT leave the patient – think safety

DO NOT “do nothing”- you always have to do something
If the question is about endorsement—always report anything new or
different to the next shift
Only select “document” if the assessment is normal
Put patients with the same or similar diagnoses in the same room-clean vs. dirty
patients
Never increase a patient’s fluids to “catch up”
Answer SATA questions as true or false for each answer option
Rephrase the question in your own words—this ensures you understand what
the question is asking—if you cannot rephrase the question, you do not know
what the topic is
If you cannot determine the topic of the question, read all answer choices to
help you understand the problem (look for patterns)
Try not to determine the answer before reading the answer choices—NCLEX
uses traps and answers that scream “pick me” but are wrong
More often than not, pain will not be your answer -- pain is considered
psychosocial—exception to this rule are signs and symptoms of compartment
syndrome
Try to focus on the here and now as much as possible
With positioning questions- you are trying to prevent or promote
something—evaluate the outcome of each option
When the question asks what is ESSENTIAL—think SAFETY
If you do not know what a word means, try to break it down using medical
terminology
o Ex: Rhabdomyosarcoma – muscle (myo), tumor (sarcoma) →
 tumor of the muscle tissue
o Same idea applies to medications- use suffixes and prefixes to
recognize classifications
Make an educated guess—if you can’t make the best answer for a question
after carefully reading it, choose the answer with the most information
When in doubt, SAFETY “Keep them breathing, keep them safe”
Prioritization Techniques
Prioritize systemic vs. local (life before limb)
Prioritize acute before chronic
Prioritize actual before potential future problems
Prioritize according to Maslow’s- physiological needs before psychosocial
(acute safety can take priority- ATI)
Recognize and respond to trends vs. transient findings (recognizing a
gradual deterioration)
Recognize signs of emergencies and complications vs. “expected client
findings”
Apply clinical knowledge to procedural standards to determine the priority
action- recognizing that the timing of administration of antidiabetic and
antimicrobial medications is more important than administration of some other
medications
How to tackle- WHO DO YOU SEE FIRST- questions:

Who is your most stable patient? ELIMINATE ANSWER

Who is your most stable patient (of the 3 remaining)? ELIMINATE
ANSWER
Who is your most unstable patient (of the 2 remaining)? Airway?
Breathing? Circulation? SELECT ANSWER

TRANSMISSION-BASED PRECAUTIONS
Chicken pox can be rapidly transmitted to other clients—should be isolated

quickly and placed in negative pressure room
(Also, Hep A)
A nurse with localized herpes zoster CAN care for patients as long as the
patients are NOT immunocompromised and the lesions are covered!
*Private room or cohort, mask (door open, 3ft distance)
Current CDC evidence-based guidelines indicate that droplet precautions

for clients with meningococcal meningitis can be discontinued when

the client has received antibiotic therapy for 24 hours!
Current CDC guidelines indicate that rapid implementation of standard,
contact, and airborne precautions are needed for any client suspected
of having SARS—in order to protect other clients and healthcare workers
SKIN INFECTIONS
VCHIPS
V- varicella zoster
C- cutaneous diphtheria H- herpes simplex
impetigo
P- pediculosis
S- scabies
Impetigo- caused by Staph and Strep, untreated can cause acute

glomerulonephritis (periorbital edema—indicates poststreptococcal
glomerulonephritis)
Order of PPE Application

Gown
Mask
Goggles/face shield
Gloves
Order of PPE Removal (Alphabetical like Dictionary)

Gloves
Goggles/face shield
Gown
Mask

Because the hands of health care workers are the most common means of
transmission of infection from one client to another, the most effective method
of preventing the spread of infection is to make supplies for hand hygiene
readily available for staff to use.
Because the respiratory manifestations associated with the avian influenza are
potentially life threatening, the nurse’s initial action should be to start oxygen
therapy!
S/S: SOB, diarrhea, abdominal pain, epistaxis
Institute airborne and contact precautions
According to the CDC, catheter associated UTIs are the most common health
care-acquired infection in the US—primary CDC recommendations include
avoiding the use of indwelling catheters and the removal of catheters as soon
as possible!
Individuals who have contact with infants should be immunized against

pertussis in order to avoid infection and to prevent transmission to the infant!
The ventilator bundle developed by the Institute for Healthcare Improvement

includes recommendations for continuous elevation of the head of the bed
(30 to 45 degrees), daily assessment for extubation readiness, and daily
oral care with chlorhexidine solution.
Chlorhexidine is more effective than the other options at reducing the risk
for central-line associated bloodstream infections (CLABSIs)
No pee, no K (do not give potassium without adequate urine output)
ElVate Veins, dAngle Arteries for better perfusion
*IV push should be given over 2 minutes*
CONVERSIONS
1 oz 30 mL
1 cup 8 oz
1 kg 2.2 lbs
1 lb 16 oz
1 gr (grain) 60 mg
*Convert C to F: C + 40 multiply by 9/5 and subtract 40
*Convert F to C: F + 40 multiply by 5/9 and subtract 40

POSITIONING
Asthma
o Orthopneic position where patient is sitting up and bent forward with
arms support on a table or chair arms
Air Embolism- (S/S: chest pain, difficulty breathing, tachycardia,

pale/cyanotic, sense of impending doom)
o Turn patient to LEFT side and LOWER head of bed
Pulmonary Embolism- (S/S: chest pain, difficulty breathing, tachycardia,

pale/cyanotic, sense of impending doom)
o Elevate HOB
Women in Labor with non-reassuring FHR-

o (S/S: late decels, decreased variability, fetal bradycardia, etc.)
o Turn mother on LEFT side (and give O2, stop Pitocin, increase IV fluids)
Tube Feeding w/ Decreased LOC

o Head of bead ELEVATED (to prevent aspiration) and position patient on
o RIGHT side (promotes gastric emptying)
Postural Drainage
o Lung segment to be drained should be in the uppermost position to allow
gravity to work
During Epidural/Lumbar Puncture

o Side-lying (“C” curved spine)- lateral recumbent/fetal position
Post Lumbar Puncture (LP) – (and also oil-based myelogram)

o Patient lies in flat supine (to prevent CSF leak and headache) for 2-3
hours
o Sterile dressing applied
o Frequent neuro checks
Thoracentesis
o Position patient with arms on pillow over bed table or lying on side
o NO MORE THAN 1000cc at one time
o Post- check blood pressure, auscultate bilateral breath sounds, check
for leakage, sterile dressing
Patient with Heat Stroke

o Lie flat with legs elevated
Hemorrhagic Stroke
o HOB elevated 30 degrees to reduce ICP and facilitate venous drainage
Ischemic Stroke

o HOB flat (supine)
During Continuous Bladder Irrigation (CBI)- catheter is taped to thigh

o Leg should remain straight to prevent pulling on catheter
o
Post Myringotomy- surgical incision in eardrum to relieve pressure and
drain fluid (tubes)
o Position on side of affected ear after surgery (allows drainage of
secretions)
Post Cataract Surgery

o Patient will sleep on unaffected side with night shield for 1-4 weeks
(adequate vision may not return for 24 hours)
o Pain that is not relieved by prescription pain medication may signal
hemorrhage, infection or increased ocular pressure
Infant with Spina Bifida

o Position prone (on abdomen) to prevent sac from rupturing
Buck’s Traction (skin traction)

o Elevate foot of bed for counter-traction
Post Total Hip Replacement

o DON’T sleep on affected/operative side
o DON’T flex hip more than 45-60 degrees
o DON’T elevate HOB more than 45 degrees
o Maintain hip abduction by separating thighs with a pillow
 NO adduction or internal rotation
Cord Compression/Prolapsed Cord

o Knee-chest or Trendelenburg (goal is to prevent pressure on cord)
Vena Cava Syndrome (pregnant women)

o Position woman on her left side (relieves pressure off vena cava from
fetus)—knees flexed (blood return)
o Mother may present with hypotension
Infant with Cleft Lip

o Position on back or in an infant seat to prevent trauma to suture line
o While feeding, hold in upright position
Infant with Cleft Palate

o Prone
Pancreatitis
o Patients should lie in fetal position
o Maintain NPO status (to rest the gut)—patient may also have PICC
line inserted for TPN/lipids

To Prevent Dumping Syndrome
o Eat in reclining position
o Lie down after meals for 20-30min
o Restrict fluids during meals, low carbohydrate, low fiber, high fat and
protein
*GOAL: decrease gastric motility

Enema Administration
o Position patient in left-side lying (Sim’s position) with knees flexed
Above Knee Amputation

o Elevate for first 24 hours on pillow
o Position prone daily to provide for hip extension
o Do not keep leg elevated beyond 24 hours—causes hip flexion which
can lead to contractures
o Rewrap 3x day (elastic bandages)
Below Knee Amputation

o Foot of bed elevated for first 24 hours
o Position prone daily to provide for hip extension
o Do not keep leg elevated beyond 24 hours—causes hip flexion which
can lead to contractures
Activity helps reduce the frequency and degree of phantom pain Detached
Retina
o Area of detachment should be in the dependent position (head in
 downward direction, lying on unaffected side)
After Supratentorial Surgery (suture behind hairline)

o Elevate HOB 30-45 degrees
After Intratentorial Surgery (incision at nape of neck)

o Position patient flat and lateral on either side
During Internal Radiation
o On bed rest while implant is in place

(Common NCLEX TOPIC)
Autonomic Dysreflexia/Hyperreflexia (S/S: pounding H/A, profuse
sweating, nasal congestion, goose flesh, bradycardia, HTN)
o Place patient in sitting position- HIGH FOWLER’S (elevate HOB-
FIRST ACTION)—decreases venous return
o Check for kinks in foley catheter tubing
Spinal Cord Injury

o Immobilize on spine board
o Head in neutral position
o Immobilize with padded C-collar
o Maintain traction and alignment of head manually
o Log roll client and do not allow to twist or bend
Shock
o Bed rest with extremities elevated 20 degrees, knees straight, head
slightly elevated (modified Trendelenburg)
Head Injury
o Elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis when Outflow is Inadequate

o Turn patient from side to side BEFORE checking for kinks in tubing
(according to Kaplan)
Nasogastric Tube
o Elevate HOB 30 degrees to prevent aspiration
o Maintain elevation for continuous feeding or 1 hour after intermittent
feedings
Cardiac Catheterization
o Keep site extended (usually involves femoral artery)
Post-thyroidectomy
o Semi-Fowler’s position, prevent neck flexion/hyperextension (support
head, neck and shoulders)
o Trach at bedside
o Monitor respiratory status every hour
Post-Bronchoscopy
o Semi Fowler’s
o Check V/S q15 min until stable
o Assess for respiratory difficulty (stridor, dyspnea resulting from
laryngeal edema or laryngospasm)
Epistaxis

o Upright and lean forward (prevent blood from entering the stomach and
to avoid aspiration)
Pelvic Exam
o Lithotomy position
Rectal Exam
o Knee-chest position, Sim’s, or dorsal recumbent
Post-Liver Biopsy
o Place patient on right side over a pillow to prevent bleeding (liver is
very vascular)
o No heavy lifting for 1 week’
Paracentesis
o Semi-Fowler’s or upright on edge of bed
o Void prior- prevent puncture of bladder
o Post- V/S (BP), report elevated temp, observe for signs of hypovolemia
Pneumonia
o Lay on affected side to splint and reduce pain
o Trying to reduce congestion: the sick lung goes up
Post-Appendectomy
o Position on right side with legs flexed
GERD
Lay on left side with HOB elevated 30 degrees (increases sphincter
pressure)
Postural Drainage
o Head in dependent position
Post-Radical Mastectomy
o Position in Semi-Fowler’s with arm (affected side) elevated – if left
mastectomy, elevate left arm, if right mastectomy, elevate right arm!
 This facilitates removal of fluid through gravity and enhances
circulation

THINK POSITIVELY AND YOU CAN ACHIEVE GREAT
THINGS!
Prior to liver biopsy it is important to check lab results for PT time (vascular
organ)
Liver biopsy- (prior) administer Vitamin K, NPO at midnight, teach patient

that he will be asked to hold breath for 5-10 sec, supine position with upper
arms elevated
Morphine is contraindicated in pancreatitis—it causes spasm of the Sphincter

of Oddi—Demerol is the pain medication of choice!
*After pain relief, it is important to cough and deep breathe in pancreatitis—
because fluid is pushing up in the diaphragm
*With chronic pancreatitis, pancreatic enzymes are given with meals
Diabetes Mellitus- pancreatic disorder resulting in insufficient or lack of

insulin production leading to elevated blood sugar
o Type I (insulin dependent)- immune disorder, body attacks insulin
producing beta cells with resulting Ketosis (result of ketones in blood
due to gluconeogenesis from fat)
 Excessive thirst and weight loss are characteristic of T1DM
o Type II (insulin resistant)- beta cells do not produce enough insulin or

body becomes resistant
NCLEX Points
o Assessment
 3 P’s - Polyuria (excessive urination), polydipsia (extreme thirst),
polyphagia (excessive hunger)
 Elevated blood sugar
 Blurred vision
 Elevated HbA1C
 Poor wound healing
 Neuropathy
 Inadequate circulation
 End organ damage is a major concern due to damage to vessels
 Coronary artery disease
o HTN, cerebrovascular disease
 Retinopathy
o Therapeutic Management
 Insulin
 Required for Type I and for Type II when diet and exercise
do not control blood sugar

 Assess for and teach the patient regarding peak action time
for various insulins
o Only administer short acting insulins IV
 Do not use vial that appears cloudy (NPH is the
exception)
 Patient should monitor blood sugar before, during, and after
exercise
 Patient should use protective footwear to prevent injury
 Infections and wounds should receive meticulous care
 Foot Care (inspect daily)
 Feet should be kept dry
 Footwear should always be worn (cotton socks are
recommended as well as properly fitted shoes)
 Should not wear tight fitting socks
 Sick Day – when patients with DM become ill, glucose levels
become elevated
 Continue to check blood sugars and do not withhold insulin
 Monitor for ketones in urine
 15 Rule
 If blood sugar is low, administer 15g carbohydrates (5
lifesavers, 6 oz juice)- recheck in 15 minutes
 Complications
 Lipoatrophy
o Loss of subq fat at injection site (alternate injection
sites)
 Lipohypertrophy
o Fatty mass at injection site
 Dawn phenomenon
o Reduced insulin sensitivity between 5-8AM
o Evening administration may help
o Adjust evening diet, bedtime snack, insulin dose, and
exercise to prevent early morning hyperglycemia –
adjust do not eliminate (usually intermediate acting
insulin is used)
 Somogyi phenomenon
o Night time hypoglycemia results in rebound
hyperglycemia in the morning hours

Rapid-acting insulin should only be given if food is available and
patient is ready to eat
Repaglinide is a meglitinide analog drug—short-acting agents used to prevent

post meal blood glucose elevation—should be given within 1 to 30 minutes
before meals and cause hypoglycemia shortly after dosing when a meal is
denied or omitted

Drawing up regular insulin and NPH together
Cloudy (air into NPH) Clear
(air into regular) Clear (draw
up regular) Cloudy (draw up
NPH) Or
RN- regular before NPH
Hypoglycemia requires urgent treatment

Signs and Symptoms
o Hunger
o Irritability
o Weakness
o Headache
o BG < 60
Consume 10 to 15g of carbohydrate (15-Rule)
Glucose should be retested in 15 min
Patient should eat a small snack of carbohydrate and protein if the next meal
is more than an hour away
Repeat carbohydrate treatment if symptoms do not resolve
Alcohol has the potential for causing alcohol-induced hypoglycemia—it is

important to know when the patient drinks alcohol and to teach the patient to
ingest it shortly after meals to prevent this complication
Guidelines for exercise are based on blood glucose and urine ketone level—
patients should test blood glucose before, during, and after exercise to be sure
that it is safe.
When ketones are present the patient should not exercise because they
indicate that current insulin levels are not adequate
Diabetic Ketoacidosis (DKA)- body is breaking down fat instead of sugar for

energy—fats leave ketones (acids) that cause pH to decrease
*DKA is rare in DM Type 2 because there is enough insulin to prevent
breakdown of fats
Serum acetone and serum ketones increase in DKA
As you treat the acidosis and dehydration expect the potassium to drop
rapidly → be ready with potassium replacement
Fluids are the most important intervention for DKA and HHNS
o NS or LR
Second voided urine is the most accurate when testing for ketones and
o glucose
Bringing the glucose down too much too quickly can result in increased ICP
due to water being pulled into the CSF
Urine ketone testing should be done whenever the patient’s blood glucose is
greater than 240

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
o Potassium is low due to diuresis
o Fluids are the most important intervention
o No acidosis and no ketosis
o Weight loss is a symptom
o Often occurs in older adults with T2 Diabetes
o Risk Factors
 Diuretics
 Inadequate fluid intake (dehydration)
o HbA1c- assesses how well blood sugar has been managed over 3 month
period- 4 to 6% is good; 8% or greater indicates poor control
o 7% is ideal for a diabetic
o Usually hold insulin prior to surgery and monitor blood glucose
To Remember Blood Sugar

o Hot and dry, sugar high (hyperglycemia)
o Cold and clammy, need some candy (hypoglycemia)
Laparoscopy- CO2 is used to enhance visual—general anesthesia, foley catheter

Post-op: EARLY AMBULATION to mobilize CO2
Myasthenia Gravis- decrease in receptor sites for acetylcholine- because the

smallest concentration of ACTH receptors are cranial nerves, expect fatigue
and weakness in eye, mastication/chewing, and pharyngeal muscles
o Sometimes the first sign is that the patient can’t brush their hair
o *Not enough receptor sites for Acetylcholine to bind to for activation—

leading to muscle weakness
o *Worsens with exercise and improves with rest
o Diagnosis is made via Tensilon test- improvement in muscle

weakness (short period of time) indicates a positive reaction
o Avoid alcohol, crowded places, try to reduce stress, avoid heat (sauna,
hot tub, sunbathing), spread activities throughout the day, thicken
liquids
Myasthenic Crisis: often follows some type of infection—client is at risk for

inadequate respiratory function
S/S: elevated temperature, tachycardia, HTN, incontinent of urine and stool
Cholinergic Crisis: caused by excessive medication, stop med→ Tensilon will

make it worse

Head injury Medication
o Manntiol (osmotic diuretic)—crystallizes at room temperature so
 ALWAYS use a filter needle!
Endocrine System
o Hormone o Gland
Growth Hormone (GH) Anterior Pituitary
ADH Posterior Pituitary
T3, T4 Thyroid
PTH Parathyroid
Glucocorticoids: cortisol Adrenal gland
Insulin Pancreas
*Parathyroid gland relies on the presence of Vitamin D to work
Palpate the thyroid gently- can cause thyroid storm in a patient with
hyperthyroidism
After removal of pituitary gland- watch for hypocortisolism and temporary

Diabetes Insipidus
Myxedema/Hypothyroidism- hyposecretion of thyroid hormone (TH)

resulting in decreased metabolic rate (slowed physical and mental function)
Myxedema coma- life threatening state of decreased thyroid production—
coma result of acute illness, rapid cessation of medication, hypothermia
NCLEX Points
o Assessment
 Think HYPOmetabolic state
 Cardiovascular- bradycardia, anemia, hypotension
 Gastrointestinal- constipation (GI motility slows)
 Neurological- lethargy, fatigue (due to decreased metabolic rate
—“body is slow and sleepy”), weakness, muscle aches, paresthesias
 Integumentary- goiter, dry skin, dry hair, loss of body hair
Metabolic- cold intolerance, anorexia, weight gain (due to

decreased metabolic state), edema, hypoglycemia
 Cardiac monitoring
 Maintain open airway
 Monitor medication therapy (overdose with thyroid
medications possible)
 Medication therapy- levothyroxine (Synthroid)
 Take in morning before breakfast to prevent insomnia
(on empty stomach)
 Assess thyroid hormone levels
 IV fluids
 Monitor and administer glucose as needed

*Myxedema is COLD (hypothermia)

Hyperthyroidism- excess secretion of thyroid hormone (TH) from thyroid
gland resulting in increased metabolic rate (accelerated physical and mental
function)
Causes
o Graves disease (autoimmune reaction)
o Excess secretion of TSH, tumor, medication reaction
Thyroid Storm (Thyroid Crisis)
o Extreme hyperthyroidism (life threatening) due to infection, stress,
trauma
 Febrile state, tachycardia, HTN, tremors, seizures
NCLEX Points
o Assessment
 Elevated T3, T4, free T4, decreased TSH, positive radioactive
uptake scan
 Goiter
 Bulging eyes
 Cardiac- tachycardia, HTN (increased systolic, decreased
diastolic), palpitations
 Neurological- hyperactive reflexes, emotional instability,
agitation, hand tremor
 Sensory- exophthalmos (Graves disease), blurred vision, heat
intolerance
 Integumentary- fine, thin hair
 Reproductive- amenorrhea, decreased libido
 Metabolic- increased metabolic rate, weight loss
 Provide rest in a cool quiet environment
 Anti-thyroid medications (PTU, propylthiouracil)
 Maintain patent airway
 Avoid drinks that are stimulants (increases metabolic rate)
 Caffeine- coffee, tea, soda
 Provide eye protection
 Regular eye exams
 Moisturize eyes
 Radioactive Iodine 131
 Taken up by thyroid gland and destroys some thyroid cells
over 6-8 weeks
o Avoid with pregnancy
o Monitor lab values for hypothyroidism
 Surgical removal
 Monitor airway
 Maintain in semi-Fowlers position
 Assess surgical site for bleeding
 Monitor for hypocalcemia
o Have calcium gluconate available
 Minimal talking during immediate post-op period
 (Partial-thyroidectomy) Monitor temperature post-op→

elevated temp by even 1 degree may indicate impending
thyroid crisis→ report to MD immediately

o *Think of MICHAEL JACKSON IN THRILLER
o -Skinny, nervous, bulging eyes, up all night, heart beating fast
o (Insomnia is aside effect of excess thyroid hormones—due to increased
metabolic rate—body is “too busy to sleep”)
Hypo-parathyroid: decreased calcium (implement high calcium, low

phosphorous diet; provide Vitamin D which aids in calcium absorption)
o *Trousseau’s and Chvostek’s signs
CATS (S/S):
o C- convulsions
o A- arrhythmias
o T- tetany
o S- spasms
o S- stridor
Hyper-parathyroid: increased calcium (implement low calcium, high

phosphorous diet)
o S/S: Fatigue, polyuria, muscle weakness, renal calculi (55% have urinary
tract calculi), back and joint pain, monitor for bone deformities
o Pre-parathyroidectomy- low calcium, high phosphorous diet
o *For patients who are not candidates for para-thyroidectomy, diuretics

(furosemide) and hydration (IV NS) in combo help reduce serum calcium
→ furosemide increases kidney excretion of calcium when combined with
IV saline in large volumes

BEST WAY TO EVALUATE FLUID STATUS (fluid volume
deficit)- daily weight
Hypovolemia: (dehydration) increased temperature, rapid/weak pulse
(tachycardia), increased respirations, hypotension, anxiety, urine SG > 1.030
(dark urine), confusion (early sign)
o Increased sodium with dehydration
o Increased BUN with dehydration
o Increased hematocrit with dehydration
Hypovolemic Shock
o Isotonic fluids – increase intravascular volume (NS or LR)
o Albumin can be given too (expander)
Hypervolemia: (fluid volume excess/overload) bounding pulse, SOB, dyspnea,

crackles, peripheral edema, HTN, urine SG <1.010 (dilute urine); Semi-Fowler’s
*D5W-body rapidly metabolizes the dextrose and the solution becomes

hypotonic
Low phosphorous—patient will exhibit generalized muscle weakness→ may

lead to acute muscle breakdown (rhabdomyolysis)
Phosphate is necessary for energy production in the form of ATP—when not
produced, leads to generalized weakness
Diabetes Insipidus (DI): hyposecretion or failure to respond to ADH from

posterior pituitary—leading to excess water loss
NCLEX Points
o Assessment (S/S)
 Excessive urine output
 Dilute urine (USG <1.006)
 Hypotension leading to cardiovascular collapse
 Tachycardia
 Polydipsia (extreme thirst)
 Hypernatremia
 Neurological changes
 Water replacement
 D5W if IV replacement is required
 Hormone replacement
 Desmopressin
 Vasopressin
 Monitor urine output hourly and urine SG
 Report urine output > 200mL/hour
 Daily weight monitoring

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): excessive
secretion of ADH (from posterior pituitary) leading to hyponatremia and water
intoxication (excessive water retention)
Caused by trauma, tumors, infection, medications
NCLEX Points
o Assessment (S/S)
 Fluid volume excess (HTN, crackles, JVD)
 Altered LOC
 Seizures
 Coma
 Urine specific gravity > 1.032
 Decreased BUN, hematocrit, Na (hyponatremia)
 Frequent neuro exams
 Monitor I&O
 Fluid restriction
 Sodium supplement
 Daily weight (loss of 2.2 lbs or 1 kg = 1 L)
 Medication
 Hypertonic saline (D5 w/ NS)
 Diuretics (furosemide)
 Electrolyte replacement
*Water intoxication – drowsiness and altered mental status
Specific Gravity
o 1.010-1.030
o High- (concentrated/dark urine)
 Dehydration
 SIADH
 Heart failure
o Low- (dilute/water-like urine)
o CKD
o Diabetes Insipidus
o Fluid volume overload
Hypomagnesemia (low Mg): tremors, tetany, seizures, dysrhythmias (life

threatening ventricular arrhythmias), depression, confusion, dysphagia
o *Low Mg may lead to digoxin toxicity
Hypermagnesemia (high Mg): depresses the CNS, hypotension, facial

flushing, muscle weakness, absent deep tendon reflexes, shallow respirations
o *Emergency

Addison’s Disease- hyposecretion of adrenal cortex hormones; decreased
levels of glucocorticoids and mineralcorticoids leads to hyponatreamia,
hyperkalemia, hypoglycemia, decreased vascular volume—fatal if not
treated
NCLEX Points
o Assessment
 Hyponatremia (down)
 Hyperkalemia (up)
 Hypoglycemia (down)
 Decreased blood volume (down)- anemia
 Hypotension (down) – most important assessment
parameter
 Weight loss
 Hyperpigmentation (tanned skin)
 Decreased resistance to stress
o Therapeutic Management – with Addison’s you must add
 hormone (teaching about steroid replacement is important)
 Monitor vital signs
 Monitor electrolytes
 Monitor glucose
 Treat low blood sugar
 Administer replacement adrenal hormones as needed
 Lifelong medication therapy needed
 Managing stress in a patient with adrenal insufficiency is
important—if the adrenal glands are stressed further it can result
in Addisonian Crisis
o Addisonian Crisis
 Caused by acute exacerbation of Addison’s Disease
 Causes severe electrolyte disturbances
 Monitor electrolytes and cardiovascular status closely
 Administer adrenal hormones as needed
 S/S: N/V, confusion, abdominal pain, extreme weakness,
hypoglycemia, dehydration, decreased blood pressure
 During times of stress- increase sodium intake → a decrease
in aldosterone leads to increase in excretion of sodium)

Cushing’s Disease- hypersecretion of glucocorticoids leading to elevated
cortisol levels; greater incidence in women; life threatening if untreated
NCLEX Points
o Assessment
 Hypernatremia (up)
 Hypokalemia (down)
 Hyperglycemia (up)
 Increased blood volume (up)
 Hypertension (up)
 Prone to infection
 Moon face
 Buffalo hump
 Muscle wasting
 Edema (signs of CHF)
 Risk to bruising
Therapeutic Management – you have excess “cushion” of hormones
o Monitor electrolytes and cardiovascular status
 Prevent fluid overload – respirations are the first priority
 Cardiovascular feature- capillary fragility→ results in
bruising and petechiae
o Provide skin care and meticulous wound care (paper thin skin that is
easily injured)
o Provide for client safety/ Protect client from infection
o Adrenalectomy (surgical removal of adrenal gland)
o Often caused by tumor on adrenal or pituitary gland
Pheochromocytoma- vascular tumor of adrenal medulla (adrenal glands)

leading to a hypersecretion of epinephrine/norepinephrine
S/S: persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor,
pounding headache
Management: avoid stress and frequent bathing, and take rest breaks (limit
activity), avoid stimulating foods, avoid foods high in tyramine
Avoid palpating the abdomen as it can cause a sudden release of
catelcholamines and severe HTN
Tx: surgery to remove tumor
Priority situation
o Neuroleptic Malignant Syndrome (NMS)
o NMS is like S&M
o -You get hot (increased temp/hyperpyrexia)
o -Stiff (increased muscle tone)
o -Sweaty (diaphoresis)
o -BP, pulse, and respirations go up

o -You start to drool
o *Flu like symptoms
o *Never get pregnant with a German (German measles/rubella is
the dangerous one for pregnant women)
o Exposure to rubella for a pregnant woman—incubation is 14 to 21
days (communicable 7 days before)

Pulmonary Embolism
First sign- sudden chest pain, followed by dyspnea and tachypnea
o O2 deprived—first intervention is usually oxygen (check ABGs)
 Patient may be hyperventilating as a compensatory mechanism
Risk Factors
o Obesity
o Immobility
o Pooling of blood in extremities
o Trauma (MVA)
Tetralogy of Fallot
o *Think DROP (child drops to floor or squats)
D- defect, septal
o R- right ventricular hypertrophy
o O- overriding aorta
o P- pulmonary stenosis
o For neonates with Tetralogy of Fallot- prostaglandin E1 infusion

o *Give O2 and morphine, IVF for volume expansion
MAOIs
o *Pirates say “arrrr”—when pirates are depressed they take MAOIs
o -MAOIs used for depression have an “ar” sound in the middle (parnate,
marplan, nardil)
o ..or..
PANAMA
o PArnate- tranylcypromine
NArdil- phenelzine
MArplan- isocarboxazid
o *Avoid tyramine when taking MAOIs—aged cheese, chicken liver, avocados,

bananas, meat tenderizer, salami, bologna, wine, beer—may cause HTN
crisis
Systemic Lupus Erythematous- progressive systemic inflammatory disease

resulting in major organ system failure; immune system “hyperactive” attacks
healthy tissue; no known cure
NCLEX Points
o Assessment
 Assess for precipitating factors
 UV light
 Infection
 Stress
 Arthritis
 Weakness
 Photosensitivity
 Butterfly rash

 Elevated ESR and C Reactive Protein
 Assess respiratory status
 Assess end organ function
 Plan rest periods
 Identify triggers
 Refer to dietitian for dietary assistance
 Medications
 Glucocorticoids
 NSAIDs
 Cyclophosamide (immunosuppressive agent)
**Should be in remission (SLE) at least 5 months prior to conceiving
*A high number of patients with SLE develop nephropathy, so an increase in
blood urea may indicate a need for a change in therapy or for further
diagnostic testing (such as creatinine clearance)
Albumin levels are the best indicator of long-term nutritional status (normal
3.5-5.0)
o (Same range as potassium)
One of the goals for a client with anorexia is to achieve a sense of self-worth
and self-acceptance that is not based on appearance → encourage activities
that will promote socialization and increase self-esteem
Physical S/S of anorexia

o Amenorrhea
o Constipation
o Hypotension
o Cold intolerance
o Bradycardia
o Fatigue
o Muscle weakness
o Osteoporosis
Autonomic Dysreflexia- potentially life threatening emergency (seen with

patients with spinal cord injuries)
o Elevate HOB to 90 degrees - FIRST
o Usually T6 or above spinal cord injury
o Vasoconstriction below
o Vasodilation above
o Sudden, acute onset of HTN
o Loosen constrictive clothing
o Assess for bladder distention and bowel impaction (can trigger AD)-
 SECOND
o Administer anti-HTN medications (may cause stroke, MI, seizure

o Metallic bitter taste
Thrombolytic therapy- avoid injury→ avoid activities that could cause

bleeding (NO IM injections)
*The Institute for Safe Medication Practices guidelines indicate that the use of
a trailing zero is not appropriate when writing medication orders—because
it is easily mistaken for a larger dose!
First action after medication administration error is to assess the client for
adverse outcomes
Drug Schedules
o Schedule I- no currently accepted medical use, research only (heroin,

LSD, MDMA)
o Schedule II- drugs with high potential for abuse and requires written
prescription (Ritalin, hydromorphone/Dilaudid, meperidine/Demerol,
and fentanyl)
o Schedule III- requires new prescription after 6 months or five refills
(codeine, testosterone, ketamine)
o Schedule IV- requires new prescription after 6 months (benzodiazepines)
o Schedule V- dispensed as any other prescription or without prescription
(cough preparations, laxatives)
MEDICATION CONSIDERATIONS
Digoxin- assess pulse for a full minute, hold if HR less than 60, check digoxin
levels and potassium and magnesium levels (low K and Mg can lead to
digoxin toxicity)
o S/S of toxicity- yellow halo, N/V
o *Digoxin is given with loading doses (normally 2- 0.5mg or higher)—
maintenance dose is typically 0.25mg
o **Increases ventricular irritability—can convert a rhythm to V-Fib following
cardioversion
Aluminum Hydroxide (Amphojel)- (antacid) treatment of GERD and kidney

stones- watch for constipation
o Take after meals
Amiodarone-
o treats life-threatening heart rhythm problems; watch out for diaphoresis,
dyspnea, lethargy—take missed dose any time in the day or skip it entirely—
DO NOT take double dose
Warfarin (Coumadin)-

o anticoagulant therapy; watch for signs of bleeding, diarrhea, fever or
rash; stress the importance of complying with prescribed dosage and
follow-up appointments
o Patients taking warfarin should not make sudden dietary changes,
because changing the oral intake of foods high in Vitamin K (green leafy
vegetables, some fruits) will impact the effectiveness of the medication
o
Methylphenidate (Ritalin)-
o treatment of ADHD; assess for heart related side-effects and report
immediately; child may need drug holiday because the drug stunts
growth; poor appetite- parents should watch for weight loss
Ethambutol (TB)-
o negative effect on eyes (blurred vision, eye pain, red-green color
blindness, any loss of vision—more common with high doses); liver
problems may occur
Gemfibrozil
o lowers high cholesterol and triglycerides; monitor liver functions –
increased risk of gallstones – rhabdomyolysis
Dextroamphetamine (Dexedrine)
o used for ADHD, may alter insulin needs, avoid taking with MAOI’s, take in
morning after breakfast (insomnia is a possible side effect)
Hydroxyurea-
o used to help treat sickle cell, can help reduce the number of acute
chest syndrome episodes, pain crises, and need for blood transfusions
—report GI symptoms immediately—could be sign of toxicity
Hydroxyzine (Vistaril)-
o tx of anxiety (can also be used to help with itching)- watch for dry
mouth- commonly given pre-operatively
Haloperidol (Haldol)—
o preferred antipsychotic for elderly patients—high risk of EPS (dystonia,
tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, swollen
airway)—monitor early for signs of reaction (IM Diphenhydramine can be
given)
o Side Effects- galactorrhea (excessive or spontaneous flow of milk),
lactation, gynecomastia, drowsiness, insomnia, weakness, headache
When given IM- should be given deep into large muscle mass—is very
irritating to subcutaneous tissue
*If mixing antipsychotic medications (Haloperidol, Fluphenazine,

Chlorpromazine) with fluids, incompatible with caffeine and apple

juice
Risperidone (Risperdal)-
o antipsychotic (schizophrenia)—doses over 6mg can cause tardive dyskinesia
—first line
antipsychotic in children
o Causes weight gain, impairs temperature regulation, photosensitivity,
orthostatic hypotension
Fluoxetine (Prozac)- SSRI;

o doses that are greater than 20mg should be given in divided doses
Midazolam (Versed)-
o given for conscious sedation- watch for respiratory depression and
hypotension (benzodiazepine)
o Contraindicated in patients taking protease inhibitors
Protease Inhibitors-
o antiviral drugs used to treat HIV/AIDs and hepatitis C
o *Decrease the metabolism of many drugs—including midazolam Serious toxicity
can occur when protease inhibitors are given with other medications
Rifampin-
o (treatment of TB)- watch for red/orange tears, urine
o *Decreases effectiveness of contraceptives
Propylthiouracil (PTU) and methimazole (tapazole)-

o prevention of thyroid storm
o *Tx: hyperthyroidisim
Oxybutynin is an anticholinergic agent—

o can lead to extremely dry mouth; max dose is 20 mg/day; should be taken
between meals as food interferes with absorption
Neostigmine- treats Myasthenia Gravis—

o administer to clients 45 min before eating—helps with swallowing and
chewing
o *Also reverses the effects of anesthesia
Procainamide HCl-
o given to treat PVCs- withhold if severe hypotension—adverse signs
are bradycardia and hypotension
Isoniazid (medication for TB) causes peripheral neuropathy –

o patients may be instructed to take Vitamin B6 to counter; hepatotoxicity

(monitor LFTs); should not be taken with Phenytoin (Dilantin) as it can
lead to toxicity; hypotension may occur initially but should resolve
Trimethobenzamide HCl (Tigan)-

o tx of post-op N/V and for nausea associated with gastroenteritis
Alendronate- used for treatment and prevention of osteoporosis

o Photosensitivity- wear sunscreen and protective clothing when outdoors
o Take in the morning
o If missed dose, wait until next day to take
Doxycyline-
o antibiotic; dairy products inhibit the absorption of this medication
Cholestyramine- lower cholesterol

o S/E: constipation
o Should not take with spironolactone- increases blood chloride levels
o Many interactions- anticoagulants, beta blockers, diuretics, penicillins,
hormonal contraceptives, phenobarbital
CBT- Can Block Tremors (meds for Parkinson’s)

Carbidopa/Levodopa (Sinemet)-
o sweat, saliva, urine may turn reddish brown, causes drowsiness; patients
should not take with MAOIs
o Levodopa- contraindicated for patients with glaucoma, avoid Vitamin B6,
avoid high protein diet (interferes with the body’s response to
medication)
Benztropine (Cogentin)-
o can be used for Parkinson’s, as well as to treat EPS – may lead to the
inability to move specific muscle groups or weakness (too much of an
effect)—anticholinergic (may lead to blurred vision, dry mouth)
o *Increase fluid intake
Biperiden- Anti-Parkinson’s used to counteract EPS
Trihexyphenidyl HCl (Artane)- sedative effect
Timolol (Beta Blocker)- eye drops, used for treatment of glaucoma
Propranolol (Beta Blocker)- decreases effectiveness of atorvastatin
Sulfamethaxozole/Trimethoprim (Bactrim)- antibiotic-

o do not take if allergic to sulfa- diarrhea is a common side effect, drink
plenty of fluids
Simvastatin-

o tx of hyperlipidemia, take on empty stomach to enhance
absorption at night, report any unexplained muscle pain (could
indicate rhabdomyolysis)—especially if fever is present
Bromocriptine- used to treat menstrual problems

o *Take with meals to avoid GI upset
Dabigatran- anticoagulant with NO antidote- do not take with other

anticoagulants
Gout
Probenecid (Benemid)- increases uric acid secretion in urine
Colchicine- prevention of gout
Allopurinol- acute

Hydralazine- Tx of HTN or CHF, report flu-like symptoms, rise slowly from
sitting/lying positions to prevent orthostatic hypotension, take with meals
Dicycloverine- Tx of irritable bowel- assess for anticholinergic side effects
Verapamil- CCB- tx of HTN, angina, and dysrhythmias- assess for constipation
Sucralfate-
o tx of duodenal ulcers (coats ulcer)- take before meals (1 hour)- best on
empty stomach
o *Protects from acid
Cimetidine- H2
o *Take with meals and at bedtime
S/E: constipation
Theophylline- tx of asthma and COPD

*Therapeutic drug level: 10-20 (12 letters in theophylline—12 is in between 10
and 20, also the “1” in 10 and “2” in 20 = 12)
N-Acetylcysteine- antidote for Tylenol and is administered orally
Glipizide- effective for client diagnosed with Type 2 DM, who produces minimal
amounts of insulin (oral hypoglycemic agent)
Acetazolamide (Diamox)-
o tx of glaucoma, high altitude sickness, increased ICP- DO NOT take if
allergic to sulfa
o *Can cause hypokalemia
Indomethacin (Indocin)- NSAID-

o tx of arthritis (osteo, rheumatoid, gout), bursitis, tendonitis
o *Ototoxic
Levothyroxine (synthroid)- tx of hypothyroidism- may take several weeks to

take effect, notify doctor if chest pain—take in AM on empty stomach, can lead
to hyperthyroidism
Chlordiazepoxide (Librium)- tx of alcohol withdrawal- do not take alcohol

with this (including mouth wash that contains alcohol), very bad nausea and
vomiting can occur
Terbutaline—can lead to maternal tachycardia- withhold if HR is elevated prior

to administration
Vincristine (oncovin)- tx of leukemia (anti-leukemic)- IV only
Ganciclovir (Cytovene)- used for retinitis caused by cytomegalovirus- patient

will need regular eye exams, report dizziness, confusion, or seizures
immediately
Sertraline (Zoloft)- SSRI, depression; S/E: agitation, disruption in sleep, dry

mouth

Serotonin Syndrome
o Rare, life threatening
o S/S: abdominal pain, fever, sweating, tachycardia, HTN, delirium,
myoclonus (jerky movements), irritability, mood changes
Clozapine- schizophrenia; S/E: agranulocytosis (low WBC count), tachycardia,

seizures
*Significant toxic risk associated with clozapine is blood dyscrasia
Agranulocytosis- flu-like symptoms (fever, sore throat, lethargy)
Lindane (Kwell)- Tx of scabies (lotion) and lice (shampoo)

Scabies- apply lotion once and leave on for 8-12 hours
o Lice- wash hair with shampoo and leave on for 4 minutes with hair
uncovered, then rinse with warm water and comb with a fine tooth
comb
Dantrolene (Dantrium)- treats muscle spasms caused by MS—may take a

week or more to be effective
Pentamidine- helps treat and prevent pneumocystis pneumonia

o Can cause fatal hypoglycemia—monitor blood glucose (low BG may
indicate need to change treatment)
Doxepin HCl- antidepressant

o *Signs of overdose: excitability and tremors
Premarin (conjugated estrogen tablets)- tx after menopause- estrogen

replacement
o *Estrogen can cause dry eyes
Furosemide (Lasix)- loop diuretic

o Ototoxic especially when given with other ototoxic drugs
o Monitor BP
o Monitor U/O
o Monitor K+
o Can lead to anorexia due to reduced potassium
Phenytoin (DilanTEN)- tx of seizures

o *Therapeutic drug level = 10-20
o S/E: rash (stop med), gingival hyperplasia (practice good dental
hygiene) Toxicity- poor gait + coordination, slurred speech, nausea,
lethargy, diplopia Can cause leukopenia (low WBC)- stop
medication
Thiothixene (Navane)- tx of schizophrenia- assess for EPS
Naproxen (NSAID)- used to mild to moderate pain

Can cause gastrointestinal bleeding- monitor stools for blood
5-Fluorouracil (5-FU)- chemotherapy agent
Sulindac (NSAID)- S/E are typically GI distress (GI bleeding, ulcers,

perforation of the stomach and/or intestines)
Theophylline- used for COPD and asthma (bronchodilator)
o Causes GI upset, take with food
o Avoid use of alcohol and caffeine while taking this medication
o Watch for toxicity (10 to 20 is therapeutic range)- >20 is considered
toxic (persistent nausea and vomiting are signs)
o Many drug interactions
Dopamine- treatment of hypotension, shock, low cardiac output, poor perfusion

to vital organs (ex: kidneys)- monitor EKG for arrhythmias, monitor BP
Phenobarbital CAN be taken during pregnancy- phenytoin is contraindicated
*All psych meds (except Lithium) have the same side effects- SNS
(exception is hypotension)
SNS- increase BP, HR, and RR, dilated pupils (blurred vision), urinary retention,
constipation (decreased GI motility), constricted blood vessels, and dry mouth
Only specific medications require double verification
Epidural
o When doing epidural anesthesia, hydration beforehand is a priority
o Hypotension, bradypnea and bradycardia are major risks and emergencies
o Patients will have a foley catheter due to the inability to void

FORGET YOUR PAST MISTAKES AND FOCUS ON YOUR
SUCCESSES!
When caring for a pregnant woman who follows a vegetarian diet, the nurse
should begin with an assessment of the diet (24 hour diet recall) because
vegetarian practices vary widely—assess the diet for deficiencies before
making recommendations for supplementation
Maternity Normal Values

o Fetal Heart Rate- 120 to 160 bpm
o Amniotic fluid- 500- 1200 mL
o APGAR- 7 and above = normal; 4 to 6 fairly low; 3 and below are
critically low
o Done at 1 and 5 minutes
Prenatal vitamins should be taken with something acidic (orange juice) at

bedtime (Vitamin C increases absorption)
Pregnant women should increase calories by 300 for fetal growth, maternal
tissues and placenta
Placenta previa requires c-section
Hyperemesis gravidarum- bed rest, NPO to rest GI tract, anti-emetics, IVF
Symptoms of onset of labor

o Gush of fluid down legs
o Some blood in vaginal discharge
o Low back pain
Fetal Heart Rate Patterns

VEAL CHOP
o VC EH
AO LP
o V= variable decels, Cord compression

o E = early decels, Head compression
o A = accelerations, OK
o L = late decels, Placental insufficiency (baby is not receiving enough oxygen
and nutrients)

*For cord compression, place the mother in TRENDELENBURG position-
this removes the pressure of the presenting part from the cord (baby is no
longer being pulled out of the body by gravity)
If the cord is prolapsed- cover it with sterile saline gauze to prevent drying of
the cord and to minimize infection
*For late decels, turn the mother on the left side to allow more blood to flow
to the placenta- give mother O2 via face mask, stop Pitocin, open IV fluids
(increase)
*Sometimes it is hard to determine who to check on first, mom or baby—it is

usually easy to tell the right answer if the mother or baby involves a machine—if
you are not sure who to check on first, and one of the choices is a machine,
that’s the wrong answer- eliminate
If the baby is in a posterior position- the sounds are heard at the sides
If the baby is in an anterior position- the sounds are heard closer to midline,
between the umbilicus and where and where you would listen to a posterior
position
*If the baby is breech- sounds are high up in the fundus (usually above or
around the umbilicus)
*If baby is vertex (head is down), they are a little above the symphysis pubis
on the left or right side
NEVER APPLY FUNDAL PRESSURE IN THE CASE OF SHOULDER

DYSTOCIA!
A newborn discharged before 72 hours of life should be seen by an RN or MD

within 2 days of discharge
A newborn should feed between 8 and 12 times in 24 hours
ALWAYS protect the newborn’s eyes when undergoing phototherapy and

monitor temperature carefully! Breastfeeding is encouraged to avoid
dehydration and increase passage of meconium (which helps excrete bilirubin)
Normal Contraction Pattern

o Contractions every 2-5 minutes for 60 seconds (<90 seconds)
o Longer lasting and shorter intervals is NOT normal (could be a
complication of Pitocin)
Palpating uterine contractions is done with fingertips

AVA: The umbilical cord has two arteries and one vein
Amniotic fluid is alkaline- turns nitrazine paper blue

Urine and normal vaginal discharge are acidic and turn the nitrazine paper
yellow/orange (some color charts vary)
If a woman’s water breaks and she is at a (-) station, you should be concerned
about a potential prolapsed cord

Post-delivery
Pitocin should only be administered after the placenta separates from the
uterine wall
o Signs: gush of blood, umbilical cord out of vagina, uterus
contracting
Umbilical cord care: clean cord several times a day and expose to air
frequently (to encourage drying and prevent infection)
Oxytocin should always be a secondary infusion controlled by IV pump
Pregnancy weight gain:

2-5 lbs. in 1st trimester
0.6-1.1 lbs. weekly in 2nd and 3rd trimesters
Transition phase of labor- woman should pant with pursed lips→ allows client to
control pain and urge to push and promotes adequate oxygenation of fetus
Other
Methotrexate is teratogenic and should not be used by patients who are
pregnant
Administration of antiviral medications to the pregnant woman and the

newborn, cesarean birth, and avoidance of breastfeeding have reduced the
incidence of perinatal transmission of HIV from approximately 26% to 1-2%
The incidence of congenital anomalies is 3x higher in the offspring of diabetic

women—good glycemic control during preconception and early pregnancy
significantly reduces this risk
A multiparous patient in active labor with an urge to have a bowel movement

will probably give birth imminently—it is time to push—should not be allowed
up to use the bathroom at this time!
Central Lines
Jugular veins are more prone to infection
Higher risk of infection with nontunneled lines
PICC lines and midline catheters are associated with a lower incidence of
infection
Implanted ports are placed under the skin and are the least likely central line
to be associated with catheter infection

VENTILATOR ALARMS HOLD
High pressure alarm- Obstruction due to increased secretions (mucus plug),
kink in tubing, patient coughs, gags or bites
Low pressure alarm- Disconnection or leak in ventilator or patient airway cuff,

patient stops spontaneously breathing
Increased ICP and Shock- OPPOSITE V/S
o Increased ICP (Cushing’s Triad)- increased BP, decreased pulse
(bradycardia), decreased respirations
o Shock- decreased BP, increased pulse, increased respirations
Heroin withdrawal for a neonate

o -Irritable
o -Poor sucking
o -High pitched cry
o *Withdrawal seen 12-24 hours later
Heroin Withdrawal (Adult)

o Mimics S/S of fu- runny nose, yawning, fever, muscle and joint pain,
diarrhea
JEWISH- No meat and milk together
o Milk products and carbonated beverages have sodium For CPR of an infant –
brachial pulse
Test child for lead poisoning around 12 months of age
Fruits high in potassium- bananas, potatoes, citrus fruits
*Cultures are always taken BEFORE starting IV antibiotics
A patient with leukemia may have epistaxis due to low platelets
Best way to warm a newborn: skin to skin contact on mother’s chest with a
blanket
o *Below 97.7 is a CONCERN
When patient comes to hospital in active labor- nurse’s first action is to

listen to fetal heart rate
Phobic disorders-
o Systematic desensitization- relaxation and gradual exposure to anxiety
producing stimulus
GERD
Risk Factors
o Female

o Smoking
o >45 years old
o Obesity
o Caucasian
Limit spicy foods, caffeine, lie with 2 pillows
Low residue means low fiber

Fiber adds bulk- patients who are constipated should add fiber to their diet
High fiber- oatmeal, celery, green beans

Aminoglycosides (vancomycin and gentamicin) can cause nephrotoxicity and
ototoxcity if given too quickly – monitor BUN and creatinine
“Red Man” syndrome occurs when vancomycin is infused too quickly—because

the client needs the medication to treat infection, the vancomycin should not be
discontinued—antihistamines my help decrease the flushing, but vancomycin
should be administered over atleast 60 min!
ARDS (fluid in alveoli), DIC (disseminated intravascular coagulation) are always

secondary to something else (another disease process)
Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues)
o First sign is usually increased respirations → later comes
dyspnea, retractions, air hunger, cyanosis
Edema is in the interstitial space NOT in the cardiovascular space
Weight is the best indicator of hydration status (dehydration)
Wherever there is sugar (glucose), water follows
NO ASPIRIN TO CHILDREN- can cause Reye’s Syndrome (encephalopathy)

S/S of Reye’s: vomiting, lethargy, unusual sleepiness, increased RR,
diarrhea, confusion, loss of consciousness
ASPIRIN OVERDOSE SIGNS

Tinnitus
Gastric distress
COLD for acute pain (sprain, fracture), HOT for chronic pain (rheumatoid
arthritis)
Pain is usually the highest priority for rheumatoid arthritis
Cultures taken before first dose of antibiotics
Stool (+) – Salmonella → contact precautions
Detached retina- photophobia, loss of a portion of visual field
COPD is chronic, pneumonia is acute—emphysema and bronchitis are both

COPD
In COPD patients, baroreceptors that detect the CO2 level are destroyed—
therefore, O2 level must be low because high O2 concentration blows the
patient’s stimulus for breathing
o Ex: Patient is on O2 at 6L/min- this is too high→ causing high serum
oxygen levels, which results in decreased respiratory rate
Encourage pursed-lip breathing (promotes CO2 elimination)
Encourage fluids
High Fowler’s and leaning forward (tripod position)

Exacerbation- acute, distress

Gout- (acute attack)—encourage partial weight bearing
Epinephrine is always given in TB syringe
Prednisone toxicity→ Cushing’s syndrome – buffalo hump, moon face,

hyperglycemia, HTN (too much steroid)
Prednisone Adverse Effects

o Osteoporosis
o Hyperglycemia (patient may require more insulin)
o Hypokalemia
o Hypernatremia
o Fluid retention and edema
o Decreased immune response (greater risk of infection—BUT do not see
changes in bone marrow)
o Gastrointestinal bleeding—monitor stool for bleeding
o *Rapid weight gain and edema are signs of excessive drug therapy and
the dosage of the drug needs to be adjusted (contact physician to report)
Four options for cancer management: chemo, radiation, surgery,

palliative/hospice (treatment/management can be a combination of these four)
Chest tubes are placed in the pleural space

o Placed to remove air/fluid from pleural cavity
o Creates a vacuum- NEGATIVE PRESSURE
o Air in the pleural space – pneumothorax
o Blood in the pleural space – hemothorax
o Should be below chest level
o Cough and deep breathing is encouraged
o 3 chambers
 Collects drainage- should be serosanguinous
 Assess drainage q4h (if new chest tube, assess more
frequently)
 Notify MD if drainage is bright red (could indicate possible
hemorrhage)
 Should not be more than 100mL/hour
o Water seal chamber
 2 cm of water
 Creates a one way valve that allows air to come out but
nothing to go in
 Continuous bubbling is a bad sign→ air leak
 Should see gentle tidals (fluctuates with respirations)
o Suction control chamber
 Tells you how much suction is applied to the client
 MD sets the suction parameters
 Should see bubbling in suction chamber—means it is
functioning properly

o Collection chamber

What NOT to do with Chest Tubes:
o Milk the catheter
o Never try to reinsert the tube if it is pulled out
o The immediate intervention after a sucking stab wound (open) is to dress the
wound and tape it on 3 sides—allows air to escape but not reenter→ occlusive
dressing would convert the wound from open to closed→ could lead to tension
pneumothorax…which is worse!
o *After dressing the wound: chest tube, labs, IV
Continuous bubbling indicates air leak that must be identified:

o With the physician’s order, you can apply a padded clamp to the drainage
tubing close to the occlusive dressing—if the bubbling stops, the air leak
may be at the chest tube insertion, which will require you notifying the
MD
o If the air leak does not stop when you apply the padded clamp, the air
leak is between the clamp and the drainage system—you must now assess
the system to carefully locate the leak
Angina (low oxygen to heart tissue) = no dead heart tissues
Myocardial Infarction (MI) = dead heart tissue present

MI pain tends to be in morning hours
Blood tests for MI: myoglobin, CK and Troponin

o Troponin levels are elevated 3 hours after onset of MI-
most specific to cardiac muscle injury or infarction
MONA- FIRST GIVE OXYGEN
*Most common complication following MI- arrhythmias (ventricular being

the most serious)
Chest pain in a client undergoing a stress test indicates myocardial ischemia

and is an indication to stop testing to avoid ongoing ischemia, injury, or
infarction
Anti-cholesterol medications should be given with evening meal (at night)
Nitroglycerine is administered up to 3 times (every 5 minutes)—if chest pain

does not stop- GO TO HOSPITAL or call 911—do not give if blood pressure is
<90/60
Preload affects amount of blood that goes to the right ventricle, afterload is the
resistance the blood has to overcome to leave the heart

Calcium channel blockers affect afterload
DO NOT DRINK GRAPEFRUIT JUICE WITH CCB
DO NOT GIVE BLOCKERS (BETA BLOCKERS, CALCIUM CHANNEL BLOCKERS) to
PATIENTS WITH HEART BLOCK

For a CABG, when the great saphenous vein is taken, it is turned inside out
due to the valves that are inside
Unstable angina is not relieved by nitro
Prochlorperazine maleate (Compazine)- should be considered incompatible

with all other medications in syringes
Angiotensin II is a potent vasodilator (from lungs)
Aldosterone attracts sodium
THE PAST IS GONE- FOCUS ON THE PRESENT AND

FUTURE!
REVERSAL AGENTS/ANTIDOTES
o Heparin = protamine sulfate
o Coumadin = vitamin K
o Ammonia = lactulose
o Acetaminophen = n-Acetylcysteine
o Magnesium sulfate= Calcium gluconate
o Iron = deferoxamine
o Digoxin = digibind
o TPA = aminocaproic acid (amicar)
o Methotrexate toxicity = leucovorin
o Alcohol withdrawal = Librium (Chlordiazepoxide)
o Opioids/Narcotics = Naloxone (Narcan)
o Methadone is an opioid analgesic used to detox patients addicted to
narcotics
Low potassium potentiates digoxin toxicity (low Mg too)
Heparin prevents platelet aggregation
COMMON NCLEX TOPIC

PT- 10- 14 seconds – therapeutic is 1.5 to 2 times
INR- 0.8 to 1.2- therapeutic is 2 to 3 times
PTT – 20-45 seconds- therapeutic is 1.5 to 2.5 times

Oral anticoagulant therapy should be instituted 4-5 days before
discontinuing heparin therapy
Cardiac output decreases with dysrhythmias- dopamine increases blood

pressure
Med of choice for v-tach and PVCs is lidocaine
Med of choice for SVT and paroxysmal atrial tachycardia is adenosine
Med of choice for asystole is atropine
Med of choice for CHF is ACE-Inhibitor
Med of choice for burn pain management is morphine sulfate
Med of choice for candidiasis is ketoconazole
Med of choice for anaphylaxis is epinephrine
Med of choice for Status Epilepticus is benzodiazepine (valium, lorazepam)
Med of choice for bipolar is lithium
Increase fluid intake with lithium (2500-3000 mL/day)

Maintain adequate salt intake (2-3 grams per day)
S/E: increased U/O and dry mouth
No ETOH with lithium
Therapeutic level- 0.4 to 1.4
Toxic level – 2 to 3: N/V/D, tremors (give mannitol and acetazolamide if signs
of toxicity are present)
Amiodarone (anti-arrhythmic) is effective in both ventricular and atrial

complications
S3 (heart sound) is normal in CHF, not normal in MI

*May also hear S3 in fluid volume overload
Give sucralfate (anti-ulcer) before meals to coat stomach
Pantoprazole (Protonix) is given prophylactically to prevent stress ulcers

(PPI)
Always check gag reflex following endoscopy
TPN is given via subclavian line (requires central line)

Diverticulitis (inflammation of the diverticulum in the colon)- pain in LLQ
Can cause chronic or severe bleeding, if no obvious blood in the stool, the
stool may be tested for occult blood
Bipolar Disorder
*Avoid competitive games when in manic phase (leads to increase in agitation)
Schizophrenia- inappropriate affect
ETOH Dependence
Indication of need for more sedation- steadily increasing vital signs—client is
approaching DTs
Appendicitis (inflammation of the appendix)- pain is in RLQ with rebound

tenderness
Portal hypertension + albuinemia = ascites Beta
cells of the pancreas produce insulin
Trousseau (carpal spasm with upper arm compression) and Chvostek’s sign
(facial nerve) are observed in hypocalcemia
Chvostek- twitching- tapping face just below and in front of ear—neuro

manifestation
Never give K+ in IV push

Blood Transfusions
o ALWAYS ALWAYS ALWAYS NORMAL SALINE
o Use Y-connector
o Large-bore needle should be used (usually 20 gauge)
o Should be infused as soon as possible after they are obtained
o If patient presents with S/S of reaction- STOP the INFUSION!
Types of Reactions
o Allergic- Mild facial flushing, hives/rash, increased anxiety, wheezing,
dyspnea, hypotension
o Febrile- Fever, chills, anxiety, headache, tachycardia, tachypnea
o Hemolytic- N/V, pain in lower back, hypotension, tachycardia, decreased
urinary output, hematuria, fever, chest pain
*FOR ALL REACTIONS- Stop infusion and maintain line with NS

o Also supportive care (oxygen, Benadryl, airway), obtain urine specimen,
blood product goes back to lab

Avoid douching before pap smear—affects appearance of cells in vaginal smear
Mineral (fludrocortisone- help manage bp) and glucocorticoids (hydrocortisone)

are given in Addison’s disease
Sign of fat embolism- petechiae- treated with heparin For
knee replacement- use CPM machine
Give prophylactic antibiotic therapy before invasive procedures
Glaucoma patients lose peripheral vision- treated with medications

Cataracts- cloudy, blurry vision – treated by lens removal-surgery
CO2 causes vasoconstriction
Most spinal cord injuries are at the cervical or lumbar regions

Flaccid bladder- GOAL- want to promote acidic urine
Client should drink cranberry juice, tomato juice, bouillon
Autonomic dysreflexia (life threatening- inhibited sympathetic response of

nervous system to harmful stimulus- spinal cord injuries at T7 or above)-
usually triggered by a full bladder
Spinal shock occurs immediately after spinal injury
Multiple Sclerosis- chronic progressive disease with destruction of myelin

sheath, disruption in nerve impulse conduction—affects white matter of the
brain and spinal cord
o *Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity
are common symptoms – UTIs are common and may lead to sepsis
o Motor: limb weakness, paralysis, slow speech
o Sensory: numbness, tingling, tinnitus

o Cerebral: nystagmus, ataxia, dysphagia, dysarthria
Huntington’s Chorea- autosomal dominant disorder (50% chance of

inheriting)
o S/S: chorea (jerky, involuntary movement effecting shoulders, hips, and
face); gait deteriorates with no ambulation, no cure, palliative
Guillan-Barre Syndrome = ascending paralysis (feet to head)- watch for

respiratory system challenges
Parkinson’s = RAT → R- rigidity, A- akinesia (loss of muscle movement), T-

tremors
o Tx: CBT (Can Block Tremors)- Carbidopa/Levidopa, Benzotropine,
Trihexyphenidyl HCl
*Drooling in Parkinson’s is a concern—risk for aspiration (airway)
Transient Ischemic Attack (TIA)- mini stroke with no dead brain tissue
Cerebrovascular accident (CVA) – dead brain tissue
Hodgkin’s disease = cancer of lymph- very curable in early stages
Ranitidine – if taking once daily, should take at hour of sleep (absorption not
affected by food)
When pulse rate drops in a patient with a pacemaker, it is cause for concern!
Polycythemia- increase in RBCs as compensation for decrease in oxygenation-

seen in right-sided heart failure
Cor Pulmonae: right sided heart failure caused by left ventricular failure (S/S-
edema, JVD)
Pulmonary sarcoidosis leads to right sided HF
DO NOT PICK COUGH over TACHYCARDIA for signs of CHF in an infant!
Cerebral palsy = poor muscle control due to birth injuries and/or decreased
oxygen to brain tissues
Phenytoin (Dilantin) therapeutic level – 10-20; can cause gingival

hyperplasia
Meningitis- nuchal rigidity, headache, photosensitivity, fever- Kernig’s

and Brudzinski’s sign
*CSF in meningitis- high protein, low glucose

Wilm’s tumor- usually encapsulated above the kidneys- causing flank pain- DO
NOT PALPATE THE ABDOMEN

Congestive Heart Failure
Ventricular gallop is the earliest sign of CHF
Early signs/stage of circulatory overload (seen in CHF) is change in character of

respirations

Rule of Nines for Burns
 Head & neck (front and back) = 9%

 Torso = 18% (upper/chest and lower/abdomen are each 9%)
 Back = 18% (upper back- 9%; lower back/buttocks – 9%)
 Each arm is 9%
 Each leg is 9%
 Groin/genitalia = 1%
*Example: If an adult had burns on both legs (9% + 9%), their groin (1%), and the
chest (9%) and abdomen (9%) – 55% of their body is burned!
This rule helps guide treatment and fluid replacement! Parkland

Formula- 4mL x kg body weight x % of total burned surface = amount of
fluid to be infused over 24 hours
**Half that amount of fluid is to be infused over the first 8 hours (minus any fluid
infused pre-hospital)
Priorities with Burns- 1) ABCs 2) Cardiac output 3) Fluids 4) Infection
Electrical burns- EKG

Chemical burn- do not touch until decontaminated (need to know the type of
chemical)
Thermal burn- breathing is the #1 concern
Smoke- look inside nose for signs of smoke inhalation
*WITH BURNS TO FACE AND CHEST- BE CONCERNED ABOUT AIRWAY
EDEMA
Important to maintain aseptic technique with burns- high risk of infection

Emergency care of partial thickness burns—remove clothing and wrap in
clean sheet
*No soaps or ointments should be used in an emergency burn
situation

BURNS
o 1st degree- red and painful
o 2nd degree- blisters
o 3rd degree- no pain because blocked and burned nerves
Birth weight doubles by 6 months and triples by 1 year of age
If HR is <100 in children, hold digoxin
Cystic Fibrosis- inherited by autosomal recessive trait

First sign of cystic fibrosis may be meconium ileus (bowel obstruction) at birth—
baby is inconsolable, does not eat, does not pass meconium
Respiratory problems are the chief concern
o Airway clearance techniques are critical (postural drainage/chest
physiotherapy)
Give aerosol bronchodilators, mucolytics and pancreatic enzymes
Cystic Fibrosis- diet
o Low fat
o High sodium
o Fat soluble vitamins- ADEK
Heart defects- Cyanotic = 3 T’s (Tetrology of Fallot, Truncus arteriosus,

transposition of the great vessels)—blood does not adequately return to the
heart→ if problem does not fix itself, or cannot be corrected surgically, CHF will
occur→ followed by death
o With right-sided cardiac catheterization- look for valve problems

o With left-sided cardiac catheterization- look for coronary complications
Rheumatic fever can lead to cardiac valve malfunctions/disease

o *Group-A strep precedes rheumatic fever
o Patients experience chorea (grimacing, sudden jerky body movements)

o Joint pain is common
o Penicillin is usually given
o Watch for antistreptolysin O to be elevated
FOCUS ON YOUR ACHIEVEMENTS RATHER THAN
YOUR FAILURES—LOOK AT WHAT YOU MANAGED
TO DO WELL AND HOW YOU CAN IMPROVE!
Traction
Skin Traction
o Buck’s Traction- used to maintain proper alignment- hip fractures- want
to maintain skin integrity and circulation
o Bryant’s
o Cervical halter
o Pelvic
Skeletal Traction
o Applied directly to a bone to reduce a fracture or maintain a
surgically manipulated bone alignment
o Pins or wires inserted through skin and soft tissue into the bone
o Balanced suspension using splints, slings, weights
External Fixation Devices

o Rigid metal frames with attached percutaneous pins or wires used to
align and immobilize
o Halo Traction- THINK SAFETY FIRST—always have a screwdriver nearby
o *Place apparatus first, then place the weights when putting a patient in
traction
Nursing Considerations for Traction

o Teach about movement
DO NOT ADJUST WEIGHTS (they should NEVER be on the floor—

not exerting pulling force)
o Report pain (look for signs of compartment syndrome)
o Maintain skin integrity and circulation
*Nurse must always follow the chain of command – report to nursing supervisor
or nurse manager

Compartment Syndrome- EMERGENCY SITUATION
Paresthesia and increased pain are classic symptoms—neuromuscular
damage is irreversible 4-6 hours after onset
A patient with a vertical c-section will more likely have another c/s
Perform amniocentesis (14-16 weeks) to check for fetal anomalies- Down

Syndrome, Trisomy 18, Trisomy 13; detect presence of AChE in neural
tube defects
*When it is performed late in pregnancy it can assess fetal lung maturity and
fetal well-being
**Administer Rhogam to Rh- women
Rhogam is a blood product—as such, for NCLEX purposes, ONLY RN’s can
administer Rhogam IM to client (do not delegate to LPN/LVN

Indirect Coomb’s Test- Negative (normal) result means no antibodies are
found; positive (abnormal) result means antibodies were found—DO NOT
ADMINISTER RHOGAM TO A WOMAN WHO IS POSITIVE!
RhoGAM must be given prior to the Rh negative women

becoming sensitized... which is why RhoGAM is given prophylactically:
During pregnancy (at 28-30 weeks) or any time the mother is exposed to fetal
blood (such as after an amniocentesis, miscarriage, etc)
Then after the birth of each Rh positive newborn, if no antibodies are
identified in the mother (negative indirect Coombs), within 72 hours after
delivery
Nagele’s Rule: Subtract 3 months and add 7 days to first day of last menstrual
period
Anterior fontanel closes by 18 months

Posterior fontanel closes by 6-8 weeks
*Posterior closes before anterior
Caput succedaneum = diffuse edema of the fetal scalp that crosses the
suture lines- swelling reabsorbs within 1-3 days
Pathological jaundice- occurs before 24 hours and lasts 7 days
Physiological jaundice- occurs after 24 hours

Phototherapy considered for infant with total serum bilirubin >15 mg/dL at 72
hours of age
Placenta previa- bright red bleeding, no pain- NO VAGINAL EXAMS
Placental abruption- pain, no bleeding, rigid/board-like abdomen (monitor

fluid volume stauts/I&O)
Betamethasone = surfactant- given to mothers in pre-term labor to help baby’s

lungs mature before delivery – given in 2 doses (12-24 hours apart)
Magnesium sulfate- anticonvulsant for pregnant women with risk of seizures

due to HTN
*Also used as a tocolytic to halt pre-term labor – contraindicated for women with
myasthenia gravis, also with absent deep tendon reflexes
Magnesium sulfate- (CNS depressant) can cause slowing of
respirations and hyporeflexia; oliguria is another S/E
Oral (PO) medications are not recommended in labor—decreased GI motility
When breastfeeding- only wash breasts with water→ soap should be avoided as it
causes dryness

Fundal height should correlate with weeks of pregnancy
*26 weeks = 26cm
Epigastric pain in pregnancy→ usually a sign of impending convulsion

(according to Kaplan)
Crisis intervention = short term
FIVE INTERVENTIONS FOR PSYCH PATIENTS
o Safety
o Setting limits
o Establish trusting relationship
o Medications
o Least restrictive methods/environments to most restrictive
Most antidepressants take 3 weeks to take effect
Obsession = thought
Compulsion = action
Hallucinations- redirect patient
Delusions- distract patient
Thorazine, Haldol (antipsychotics) can lead to EPS
Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder

that accounts for more than 60% of all dementias
Patient’s do not do well with short term memory
Reality orientation- orient to what is going on right now
Safety and reorientation
Place calendar and clock in obvious area
Remind client of room and bathroom location
Atropine can be used to decrease secretions (drops)- blocks acetylcholine

Holding pressure on the inner canthus (eye) decreases the amount of
medication absorbed systemically (atropine drops)
*Atropine Overdose
Hot as a Hare – elevated temperature
Mad as a Hatter- change in LOC
Red as a Beet- flushed face
Dry as a Bone- thirsty
Decreased acetylcholine is related to senile dementia Dementia

Geriatric client should be encouraged to talk about his life and important
things in the past
Jill’s Favorite Medication:

Promethazine (Phenergan): anti-histamine; can be given as an antiemetic for
nausea—crosses BBB—sedative effect – monitor fluid status (anticholinergic
effects- anorexia, dry mouth and eyes, constipation, orthostatic hypotension)

Iron injections should be given Z-track method so they do not leak into SQ tissues
Diazepam is commonly used as tranquilizer—to reduce anxiety before surgery
Open wound in chest cavity- air needs to escape but not re-enter
*Three sided dressing

Auscultation of Heart Sounds- All--
Aortic
Pigs-- Pulmonic
Eat—Erb’s point
Too—Tricuspid
Much—Mitral
Cranial Nerves (mnemonic from “original GOLD”)

HYPERNATREMIA (greater than 145)
Skin flushed
Agitation
Low grade fever
Thirst
HYPONATREMIA (less than 135) Muscle

twitching
Convulsions Diarrhea
Headache Apprehension
Lethargy
Developmental
2-3 months- demonstrates head lag, able to turn head up (can lift off
mattress), tummy time, can turn side to side, cooing or gurgling noises and can
turn head to sound, palmar grasp
4-5 months- rolls from back to side (4), places objects in mouth, rolls from
front to back (5)
6-7 months- rolls from back to front, holds bottle/sippy cup, sits at 6 and waves
bye/bye; can recognize familiar faces and knows if someone is a stranger, moves
objects from hand to hand
8-9 months- stands straight at 8; sits unsupported, begins using pincer grasp,
has favorite toy, plays peek-a-boo
10-11 months- crawling, changes from a prone to a sitting position (belly
to butt), grasps rattles by its handles, finger foods
12-13 months- sits down from a standing position without assistance, starts
walking (uses furniture to cruise), tries to build a two-block tower without
success; cries when parents leave
*Twelve and up, drink from a cup
Hepatitis
-ends in a VOWEL and comes from the BOWEL (Hep A)
-Hepatitis B- Blood and Bodily fluids
-Hepatitis C is just like B
GLASGOW COMA SCALE

-Eyes, verbal, motor
*It is similar to measuring dating skills- max 15 points, one can do it!
If below 8, you are in a coma
-To start dating, you have to open your EYES first- if you are able to do that
spontaneously and use them correctly to SEE whom you are dating, you earn 4
points—but if she has to scream at you to make you open them it is only 3
points. If you dare not to open your eyes, even if she kicks you, you only get 1
point!
-If you get good EYE contact (4 points) then move on to VERBAL—talk to
her/him, if you can do that you are oriented (4 points)—if you like her try not to
be CONFUSED (3 points), and of course do not use INAPPROPRIATE

WORDS (3 points) because she won’t like it—try not to respond with
INCOMPREHENSIBLE SOUNDS (2 points)—but if you just don’t like her—do
not respond at all- NO VERBAL RESPONSE (1 point)
-Since you now have EYE and VERBAL contact you can MOVE to Motor
Response- this is VERY important, because good moves give you 6 points!

YOU’RE SIMPLY THE BEST- BETTER THAN ALL
THE REST!
The person who hyperventilates is likely experiencing respiratory alkalosis
Avoid salt substitutes when taking digoxin and K-supplements—because they

contain high levels of potassium
Signs of hypoxia: restless, anxious, cyanotic, tachycardia, increased

respirations (also monitor ABGs)
For blood types: “O” is the universal donor (remember “O” in donor)
“AB” is the universal recipient
**In emergency situations where typing and cross-matching have not yet been
completed, “O“ can be given!
Medications to be given with food: NSAIDs, corticosteroids, medications for

Bipolar Disorder, cephalosporins, and sulfonamides
When using a bronchodilator in conjunction with a glucocorticoid inhaler,
administer the bronchodilator first!
Theophylline increases the risk of digoxin toxicity and decreases the

effects of lithium and phenytoin
Peptic ulcers caused by H. pylori are treated with Metronidazole (Flagyl),

Omeprazole (Prilosec), and Clarithromycin (Biaxin)—this treatment kills bacteria
and stops production of stomach acid- it does not heal the ulcer!
A board-like abdomen with shoulder pain is a symptom of a perforation,

which is the most lethal complication of peptic ulcer disease
Projectile vomiting can be a signal of obstruction in the GI tract
Diaphragm must stay in place for 6 hours after intercourse

*Also must be re-fitted if patient loses or gains a significant amount of weight!
Best time to take medications:

Growth Hormone (PM) Steroids
(AM)
Diuretics (AM) – prevent nocturia
Donepezil (Aricept) (AM)- Alzheimer’s medication
Cholesterol medications (PM)
Sulcrafate (before meals)- acts as a mucosal barrier—S/E: constipation
Cimetidine (with meals and/or at bedtime)- many interactions
Antacids (1 hour after eating or when experiencing heartburn)- large amounts of
antacid consumption can lead to osteoporosis

Glaucoma- intraocular pressure is greater than normal—give miotics to
constrict (pilocarpine) – NO ATROPINE
Tonometer is used to measure IOP and diagnose glaucoma
o Normal- 10 to 21 mmHg (according to Kaplan)
Dietary calcium- dairy products, seafood, nuts, broccoli, spinach

Non-dairy sources of calcium- RHUBARB, SARDINES, COLLARD GREENS
Daily calcium intake- 1000 to 1500mg
With low back pain/aches, bend knees for pain relief (William’s position)
When taking allopurinol, patients should increase fluids to flush uric acid out
of system!
Koplik’s spots are red spots (commonly found in mouth) with a bluish/whitish
center—characteristic of PRODROMAL phase of MEASLES
Tuberculosis (TB)- medications must be taken for 6 to 9 months

Endemic to Asia, Middle East, Africa, Latin America, Caribbean
A positive PPD confirms infection, not just exposure—a sputum test

confirms active disease
PPD is (+) if induration is:

>5mm for immunocompromised patients
>10mm for high risk populations (IV drug users, recent immigrants, lab
personnel, children <4 years)
>15mm positive in any person (patients with no risk factors)
If a TB patient is unable/unwilling to adhere with treatment—may need

supervision (direct observation) → TB is a public health risk
TB medications are toxic to the liver Adverse

reaction is peripheral neuropathy
Most accidental eye injuries (90%) could be prevented by wearing eyewear

for sports and hazardous work
Eye Drop Application

Apply eye drops to the conjunctiva sac—apply pressure to lacrimal duct/inner
canthus (prevents systemic absorption)
Trendelenburg test for varicose veins—patient lies in supine position, leg is

flexed at the hip and raised above the heart, the veins will empty due to gravity
(or with the assistance of the examiner’s hand squeezing the blood towards the
heart)—a tourniquet is then applied around the upper thigh to compress the
superficial veins but not too tight as to occlude the deeper veins—the leg is then
lowered and the patient is asked to stand. If the superficial veins fill more
rapidly (than 30-35 seconds) with the tourniquet, there is valvular

incompetence below the level of the tourniquet in the “deep” veins—after 20
seconds, if there is no rapid filling, the tourniquet is released—if there is
sudden filling at this point, it indicates that the deep veins are competent but
the superficial veins are incompetent!
*If superficial veins fill with tourniquet—deep veins are incompetent
*If there is sudden filling after tourniquet it removed—superficial
veins are incompetent
Precautions when giving KAYEXALATE

Assess for dehydration (K+ has inverse relationship with Na—when you
decrease potassium, sodium increases)
Assess patient for bowel sounds before administering—if hypoactive or
absent bowl sounds—HOLD
Monitor for electrolyte imbalances
Interactions
o Caution with Digoxin (hypokalemia can lead to digoxin toxicity)
o Kayexalate may decrease the absorption of lithium
o Kayexalate may decrease the absorption of thyroxine
Yogurt has live cultures- do not give to immunocompromised patients
For itching under a cast- cool air via blow dryer, ice pack on cast for 10-15
minutes—NEVER stick anything in the cast to scratch the area
After PERITONEAL DIALYSIS- it is OKAY to have abdominal cramps, blood

tinged outflow, and leaking around the site IF it was placed in the last 1-2
weeks—IT IS NEVER NORMAL to have CLOUDY OUTFLOW
Amniotic fluid- yellow with particles = meconium stained (baby is stressed)
Hyper-reflexes- upper motor neuron issue (“your reflexes are over the top”)
Hypo-reflexes (absent)- lower motor neuron issue
Order of Assessment- (IPPA) Inspection, Palpation, Percussion, and

Auscultation→ EXCEPT with abdomen—you do not want to activate the bowels
with your assessment so the order is: inspection, auscultation, percussion,
palpation (also, if patient is presenting with abdominal problem, palpation and
percussion may be painful so should be left for the end)
SIGNS
Murphy’s Sign- pain with palpation of gall bladder area (seen with
cholecystitis)
Cullen’s Sign- ecchymosis in umbilical area, seen with pancreatitis
(bruising)
Turner’s Sign- ecchymosis (grayish blue) over flank areas- sign of
pancreatitis (bad sign)
McBurney’s Point- pain in RLQ indicative of appendicitis
Rebound tenderness in RLQ—appendicitis
RLQ pain- appendicitis, watch for peritonitis

LLQ pain- diverticulitis (should maintain low reside diet, no seeds, nuts, peas)

Guthrie Test- tests for phenylketonuria in newborns—babies should eat
source of protein first
Allen’s Test- occlude both ulnar and radial arteries until hand blanches, then
release ulnar—if the hand returns to pink color—ulnar artery is good and you
can use for ABG/radial arterial line/stick as planned—ABGs must be drawn in a
heparinized tube, placed on ice and sent immediately to lab—should also
inform lab of how much oxygen the patient is on (and via NC, mask, etc.)
Schilling Test- tests for pernicious anemia—how well one absorbs
Vitamin B12
LATEX ALLERGY-
Assess patient for allergies to bananas, apricots, cherries, grapes, kiwis,

passion fruit, avocados, chestnut, tomatoes, peaches (also see above
diagram)
Amyotrophic Lateral Sclerosis (ALS) is a condition in which there is

degeneration of motor neurons in both the upper and lower motor neuron
systems
Transesophageal Fistuala (TEF)- esophagus does not fully develop (this is a

surgical emergency)
*The 3 C’s of TEF in newborn
Choking
Coughing
Cyanosis
The MMR vaccine is given SQ not IM

-First dose recommended between 12 months and 15 months
-Contraindicated with allergy to gelatin and neomycin (also should not be given
to immunocompromised patients because it is a live vaccine)
-Should not be given to pregnant women
-Because MMR is a live vaccine, it is not uncommon to spike a fever

Triage in Disaster/Mass-Casualty Situations
*Greatest good for the greatest number
Red- IMMEDIATE/EMERGENT: unstable, injuries are life threatening but
survivable; do not delay treatment—airway, breathing, and circulation
Ex: Airway obstruction, shock
Yellow- URGENT: major injuries that require treatment; can delay treatment
1-2 hours
Ex: Open fracture
Green- NONURGENT: minor injuries that do not require immediate treatment,

can delay 2 to 4 hours
Ex: “Walking wounded”, closed fracture, contusions
Black- EXPECTANT: expected and allowed to die, prepare for morgue, comfort
measures if possible
Ex: Profound hemorrhage, cardiac arrest
DOA- Dead on Arrival
Orange- psychiatric, non-urgent
Greek heritage- use of protective charms or amulet (necklace) around baby’s

neck to protect against evil
4 year old kids cannot interpret TIME—they need time to be explained in

relationship to a known common event—Ex: Mom will be back after supper
Allergies and Interactions

Hep B Vaccine – should not receive if allergy to yeast
Hep A Vaccine—should not receive if pregnant
Flu shot—should not receive if allergy to eggs (also contraindicated for
patient’s with a history of Guillain Barre)—OK to give to
immunocompromised patients
o If a child has a cold, it is okay to give immunizations
DTaP/Tdap- contradindicated with occurrence of seizures within 3 days of
vaccine (possible adverse reaction- seizures)
o High fever 48 h after DTap is a valid contraindication for vaccine
Rotavirus Vaccine- do not give if allergy to mycin drugs
(aminogylcosides)
Varicella Vaccine- should not receive if allergy to gelatin and neomycin or

immunocompromised
Meningococcal Vaccine- should not receive if history of Guillain Barre)
HPV Vaccine- should not receive if allergy to yeast and/or pregnancy
Penicillins and cephalosporins- crossover allergy (question orders of
administering med if patient has documented/known allergy to either
Aspirin and Naproxen- crossover allergies with NSAIDs

Adult Immunizations Schedule
Tetanus booster- every 10 years
MMR- one or two doses at ages 19 to 49
Varicella- two doses if no history of disease
Pneumococcal (PPSV)- once after the age of 65; recommended for
immunocompromised, COPD, and living in long-term care facility
Hepatitis A- two doses for high risk clients
Hepatitis B and HPV- three doses for high risk clients (Hep B repeated @ 1 and
6 months)
o HPV should be given ideally before the patient is sexually active
Seasonal influenza- annually; give to immunocompromised
Meningococcal vaccine- students entering college, adults older than 65
repeat every 5 years for high-risk clients
Herpes zoster- over age 60
Live Vaccines- do not give to immunocompromised and pregnant women

MMR
Varicella
Nasal spray (flu)
When on nitroprusside, monitor thiocynate (cyanide)—normal value should be 1

→ >1 is heading towards toxicity
Severe Acute Respiratory Syndrome (SARS)—airborne and contact (just like

varicella)
Hepatitis A is contact precautions

Not infectious within a week or so after onset of jaundice
Tetanus, Hepatitis B, HIV are STANDARD precautions Avoid
high fat diet for Hepatitis B
NO VITAMIN C with ALLOPURINOL
No longer contagious after 24 hours of antibiotics

HIV
Medications need to be taken very consistently—failure to take the
medications daily can lead to mutations and the emergence of more
virulent forms of the virus
Viral load testing measures the amount of HIV genetic material in the blood, so
a decrease in the viral load indicates that the HAART is effective
Rapid HIV testing must be confirmed by another test, usually Western blot test
Infants born to an HIV-positive mother should receive all
immunizations on schedule
A positive Western blot in a child < 18 months (presence of HIV
antibodies) indicates only that the mother is infected – two or more
positive P24 antigen tests will confirm HIV in children <18 months—P24
can be used at any age
Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent
secondary infection
Avoid OPV (polio) and varicella vaccines in HIV + (both live)→
pneumococcal and influenza are OKAY
o MMR is only avoided if severely immunocompromised
o Parents should wear gloves for care, avoid sharing utensils and avoid
kissing on the mouth (due to immunocompromised status—not for
transmission purposes)
Signs of fractured hip: external rotation, shortening of affected leg, adduction
Rotavirus- spread via fecal-oral route- contact precautions for diapered and
incontinent patient’s
Fat embolism- blood tinged sputum (related to inflammation), elevated ESR,

respiratory alkalosis (related to tachypnea), hypocalcemia, increased serum
lipids, “snow storm” effect on chest X-ray
Complications of Mechanical Ventilation- pneumothorax, ulcers,

pneumonia (ventilator associated)
Paget’s Disease-abnormal bone destruction and regrowth; cause unknown

(may be genetic or due to virus early in life)
*S/S: tinnitus, bone pain, enlargement of bone (though weak/soft), headache,
hearing loss, reduced height, bowing of the legs, hypercalcemia
Intravenous Pyleogram (IVP)- requires bowel prep in order to better

visualize the urinary tract (bladder, kidneys, ureters, urethra)
Acid Ash Diet- meat, poultry, cheese, fish, eggs, grains, cranberries, prunes,
plums
Greenstick fractures are commonly seen in children (also known as buckle

fractures)—bends on one side and cracks on the other

BOTOX can be used for strabismus (12 and older)—patch the GOOD eye to
allow the weaker eye to get stronger

COPD patients- 2L via NC or less (hypoxic not hypercapnic drive), PaO2 in 60’s
and SaO2 of 90% is normal—chronic CO2 retainers
Amphotericin B- (Amphoterrible): treats infection caused by a fungus

*Should only be given to patients with severe, life threatening fungal infection
Side Effects: fever (common), hypokalemia
*Must premedicate- Tylenol and Benadryl can be used
Mebendazole (Vermox) is used to treat worm infections (pinworms,

roundworms, hookworms)—increase fat in diet to increase absorption
Kidney glucose threshold is 180—when the blood glucose levels exceed

160-180 mg/dL, the proximal tubule becomes overwhelmed and begins to
excrete glucose in the urine
Glucose Tolerance Test for pregnant women- results of 140 or higher needs
further evaluation
Lymes is found mostly in Connecticut
For asthma and arthritis—swimming is best
Intercostal retractions and asthma—BE CONCERNED – also, if the

asthma patient in the waiting room becomes silent—wheezer stops
wheezing (RED FLAG)
Coughing without other S/S is suggestive of asthma
Increased pulse rate with asthma—indicating decreased oxygenation
Tardive Dyskinesia- irreversible, involuntary movements of the tongue, face,

and extremities—may happen after prolonged use of antipsychotics
Akathisia- motor restlessness; treated with Anti-Parkinson medications—can

sometimes be mistaken for agitation
Before Pulmonary Function Tests (PFTs)—bronchodilators should be

withheld and they are not allowed to smoke for 4 days prior
For a lung biopsy—position patient on side of bed with arms raised up on

pillows over bedside table—have patient hold breath in mid expiration, chest
x-ray is done immediately to check for complications (pneumothorax)—sterile
dressing is applied- patient should lie on right side following biopsy
EEG- before--hold medications 24-48 hours prior (anti-seizure medications), no

caffeine or cigarettes for 24 hours prior, patient can eat, must stay awake the
night before the exam—during exam patient may be asked to hyperventilate and
watch a bright flashing light—after exam- assess patient for seizures, patient is

at an increased risk

Decorticate- towards the cord
Decorticate positioning in response to pain = CORtex involvement
Decerebrate- away from body
Decerebrate positioning in response to pain = CEREBellar, brain stem
involvement
*Definitive diagnosis for Abdominal Aortic Aneurysm (AAA)- CT Scan
WBC- shift to the left means there are a high number of immature white
blood cells present—most commonly this means there is an infection or
inflammation present and the bone marrow is producing more WBCs and
releasing them into the blood before they are fully mature
Therapeutic Drug Levels

Dilantin- 10 to 20
Theophylline- 10 to 20
Acetaminophen – 10 to 20 (do not excess 4000mg in one day)
Lithium- 0.4 to 1.4
Digoxin- 0.5 to 2.0
Osteomyelitis is an infectious bone disease- blood cultures and antibiotics—if

necessary, surgery to drain abscess
Nephrotic Syndrome- S/S edema (periorbital and generalized), dark, foamy

urine (indicating proteinuria), and weight gain due to excessive fluid
retention; also HTN
Characterized by massive proteinuria
Decreased serum albumin
Patient will receive corticosteroids
*Risk for impaired skin integrity
Glomerulonephritis- cola colored urine, HTN, edema, proteinuria

V/S q4h
Daily weights

Chronic Kidney Disease (Renal Failure)
Progressive, irreversible loss of renal function with associated decline in GFR
All body systems affected- dialysis is required
End stage renal disease occurs with GFR <15 mL/min
Causes:
o DM (leading cause)
o HTN (second cause)
o Unreversed acute kidney injury
o Glomerulonephritis
o Autoimmune disorders
NCLEX Points
o Assessment
 Azotemia (elevated BUN and creatinine)
 Cardio- HTN, hypervolemia, CHF
 Hematologic- anemia, thrombocytopenia
 Gastrointestinal- anorexia, N/V
 Neurological- lethargy, confusion, coma
 Urinary- decreased urine output, proteinuria
 Skeletal- osteoporosis
 Epoetin alfa aids in countering anemia
 Avoid administering aspirin
 Monitor K levels
 Elevated potassium can lead to EKG changes (peaked T
waves, flat P, wide QRS, blocks, asystole)
 Provide low potassium diet
 Potassium lowering medications
o Kayexalate
o Insulin
o Calcium gluconate
o Continuous cardiac monitoring
 Phosphate binders may be required to lower phosphorous levels
 Monitor daily weights
 Monitor for signs of heart failure
 Monitor electrolyte levels (will see low magnesium) and
BUN/Creatinine
 Assess peripheral nerve function and monitor for peripheral
neuropathy
 Vision can be affected- monitor and provide for a safe
environment
 Instruct client on dialysis and provide end of life care as needed
Stage I- diminished kidney reserve → function is reduced but healthier
kidney is able to compensate (polyuria and nocturia)
o GFR >90mL/min
Stage II
o GFR 60 to 89 mL/min
Stage III

o GFR 30 to 59 mL/min
Stage IV
o 15 to 29 mL/min
Stage V (End Stage Renal Disease)
o <15 mL/min
Hemodialysis- process of cleansing the blood of accumulated waste products

and fluids—used for ESRD or for the acutely ill that require short-term
treatment
Hold meds prior to hemodialysis
Monitor BP- concerned about BP
Check circulation
Weigh before and after
AV Fistula
o Auscultate for whooshing sound over fistula (bruit and thrill),
palpate for warmth and tenderness
o No weight on extremity
o No BP or blood work from fistula side
o Do not lift heavy objects
Peritoneal Dialysis- alternative method using the peritoneum to remove

fluids, electrolyte, and waste products from the blood
Warm dialysate
Allow to flow in by gravity
5-10 min inflow time- close clamp immediately
30 min of equilibriation (dwell time)
10-30 min of drainage (should be clear and pale yellow)
Monitor for complications: peritonitis, bleeding, respiratory difficulty,
abdominal pain, bowel or bladder perforation
Continuous Ambulatory Peritoneal Dialysis (CAPD)

Permanent indwelling catheter inserted into peritoneum
Fluid infused by gravity (1.5 to 3L)
Dwell time- 4 to 8 hours
Dialysate drains by gravity- 20 to 40 min
Four to five exchanges daily (7 days/week)—some elect to do it at night
Full colon can create outflow problems
Uremic Fetor- urine smelling breath (seen in patients with uremia—elevated

serum urea level)—seen in chronic kidney disease
Normal Creatinine- 0.6 to 1.2

Normal BUN- 10 to 20 (some sources say 9 to 20)
Normal GFR- 85 to 135 (<80 indicates decreased function)
Clients with kidney disease are susceptible to CNS effects (confusion and
dizziness)—dosage my need to be reduced
Signs and Symptoms of Kidney Rejection
Diffuse pain over kidney (tenderness)

Congenital Gastrointestinal Disorders Hypertrophic
Pyloric Stenosis- projectile vomit
Thickening of pyloric sphincter; genetic
Manifestations: vomiting that occurs 30-60 min after a meal and
becomes projectile as obstruction worsens
o Constant hunger
o Olive-shaped mass in RUQ
o Peristaltic wave that moves left to right when lying supine
o Failure to gain weight and signs of dehydration
Nursing Interventions
o Place child on side with head elevated when vomiting to prevent
aspiration
o Daily weight and I&O
o Monitor fluid and electrolyte balance to assess for deficits
o IV fluid replacement as needed
o NPO
o Monitor NG tube
Therapeutic Management
o Surgical incision into the pyloric sphincter (pylorotomy)
Hirschsprung’s- failure to pass meconium, ribbon-like stool

Occurs when a section of the colon is aganglionic – absence of ganglion cells
(nerves that contribute to peristalsis)—problem that prevents stool from
moving forward in the GI tract
Manifestations
o Newborn- failure to pass meconium within 24-48 hours, refusal to
eat, episodes of bilious vomit, abdominal distention
o Infant- failure to thrive, constipation, abdominal distention,
episodes of vomiting and diarrhea
o Older child- constipation, abdominal distention, ribbon-like stool,
palpable fecal mass, malnourished
o Position child on side or with head elevated when vomiting to
prevent aspiration
o Provide oral care after vomiting
o Surgical removal of the aganglionic section (colostomy may be
temporary)
o Serial rectal irrigation may be used to decompress bowel prior to
surgery
Intussusception- bloody stool (red currant jelly)

Telescoping of the intestine upon itself; not a congenital condition but often
occurs with congenital conditions such as cystic fibrosis
Manifestations
o Normal comfort interrupted by periods of sudden and acute pain

o Palpable, sausage-shaped mass in RUQ of abdomen and/or tender,
distended abdomen
o Stools that are mixed with blood and mucus (red currant jelly)
o Position child on side or with head elevated when vomiting to
prevent aspiration
o Assess for currant jelly stools
o Surgical reduction if inflating the bowel with air or administering
barium enema is not successful
o Proton Pump Inhibitors (Omeprazole)
o H2 Receptor Antagonists (Ranitidine)
Cleft Lip (CL) and Cleft Palate (CP)- aspiration

Multifactorial, but there are strong indicators of genetic or environmental
factors
Cleft palate is more common in males
Cleft lip is more common in females (THINK: you are able to better
visualize cleft lip externally—females generally care more about their
appearance—therefore, cleft lip is more commonly seen in females)
Manifestations
o Cleft lip is visible
o Cleft palate alone may only be visible when examining the mouth
o Individuals are prone to ear, nose, and throat infection
o Long-term problems include speech, hearing, and dentition
problems
o Assess respiratory status and ease of respiratory effort
o Keep suction equipment and bulb syringe at bedside
o Assess ability to suck and swallow
o Modify feeding techniques utilizing obturators, special nipples,
feeders
o Feed in upright position in frequent, small amounts, burp
frequently
o Daily weight and monitor I&O
o Repair usually completed by 12 to 18 months of age to prevent
speech problems
o Surgery may be performed in stages
Avoid Vitamin C prior to occult stool test- can lead to false +
All activities that the client participated in before a colostomy may be

resumed after appropriate healing of the stoma and incisions
Hypospadias- abnormality in which the urethral meatus is located on the

ventral aspect of the penis (below)

Epispadias- abnormality in which the urethral meatus is located on the dorsal
side of the penis (top)
Priapism- painful erection lasting longer than 6 hours
Mastectomy- complaints of “wet sheets” – could indicate hemorrhage from

operative site
Thank You Mary-

Anticholinergic Effects Can’t
Spit- dry mouth Can’t Shit-
constipation
Can’t Pee- urinary retention Can’t
See- blurry vision
When you see coffee-brown emesis—think peptic ulcer Fluid
retention- think heart problems first!
Erikson’s Stages of Psychosocial Development

Infants- 0 to 1 year
o Trust vs. Mistrust- trust develops as needs are met
Toddlers- 1 to 3 years
o Autonomy vs. Shame and Doubt- toddlers want to make choices
Preschooler- 3 to 6 years
o Initiative vs. Guilt- guilt may occur if unable to successfully complete a
task or if they are “punished” for an unsuccessful try
School-Age Child- 6 to 12 years
o Industry vs. Inferiority- a sense of industry is achieved through
advancements in learning; fears of ridicule are common
Adolescent- 12 to 20 years
o Identity vs. Role Confusion- families strongly influence personal identity,
peer groups greatly influence behavior, interest in opposite sex, career
planning, may see themselves as invincible
Young Adult- 20 to 35 years
o Intimacy vs. Isolation- ability to love deeply and commit oneself in
relationships vs. remaining uncommitted and alone
Middle Adult- 35 to 65 years
o Generativity vs. Stagnation- ability to give and care for others vs. self-
absorption and inability to grow as a person
Older Adult- 65 years and older
o Integrity vs. Despair- sense of accomplishment in life vs. feeling
dissatisfied with life
Fetal Alcohol Syndrome

IM administration for 6 month old infants- vastus lateralis
IM administration for toddlers (>18 months)- ventrogluteal
IM administration for children- deltoid and gluteus maximus
Eye Abbreviations
OU-both eyes
OS- left eye
OD- right eye (dominant side is usually right side- right eye)
Ear Abbreviations
AU- both ears

AS- left ear
AD- right ear( dominant side is usually right side- right ear)
COAL
Cane Opposite
Affected Leg

Walker
Wandering- Walker Wilma- With Always- Affected Late- Leg
Stand slightly behind the patient using a cane (on strong side)
For CT scan- assess for allergies to contrast (allergy to shellfish)
MRI- claustrophobia, NO METAL

Contraindicated for patients with pacemaker, stents, cochlear implants,
surgical implants
Titanium joint replacements CAN have MRI
Remove transdermal patches prior to MRI
Cardiac Catheterization
NPO 8-12 hours prior
Empty bladder
Check pulses and mark
Tell patient he may feel palpitations or desire to cough with dye
Post- V/S, keep leg straight (insertion site is typically in groin), maintain bed
rest 6-8 hours
Early Signs of Increased ICP

Pupil changes
Change in LOC/mental status changes
Increased ICP in Infants/Neonates

High pitched cry

Intracranial Pressure (ICP) should be < 20 mmHg –measure head
circumference—Normal ICP is usually between 10-15 mmHg (opening pressure)
Early Signs of Subdural Hematoma and Cerebral Edema

Decreased level of consciousness
Ipsilateral pupils (same side as hematoma)
Headache – usually the first symptom
NO MORPHINE WITH HEAD INJURY- MASKS SIGNS OF

INCREASING ICP
Fixed and dilated pupils represents a neuro emergency
Clear fluid draining out of ear indicates rupture of meninges and presents a
possible complication of meningitis
Self-catheterization (urine)- clean procedure (not sterile)
Strabismus- sign: child closes one eye to see a poster on the wall—visual
axes are not parallel so the brain receives two images
Do not need to restrict fat post-op
Cholecystectomy
T-Tube
o Post-cholecystectomy
o Used to drain bile—if change in urine color, bile is draining into the liver
o Should not be irrigated, aspirated or clamped without a specific order
from the physician
Hemovac- closed system (requires negative pressure)

Used often after mastectomy
Empty when full or q8h
Remove plug, empty contents, place on flat surface, cleanse opening and plug
with alcohol sponge, compress evacuator completely to remove air,
release plug, check system for operation

Anthrax-not spread person to person (can be spread from contaminated clothing
—so patients should undergo decontamination—removal and disposal of clothing
and showering is the initial action in possible anthrax exposure)
According to the CDC, antibiotics should be administered only if there are signs
of infection or the contaminating substance tests positive for anthrax
(LaCharity)
o Ciprofloxacin is the antibiotic used to combat anthrax
 Teaching for Ciprofloxacin
 Drink plenty of fluids
 Avoid taking a multivitamin within 6 hours of taking this
medication
 Avoid exposure to sun
 Avoid caffeine
 May take with meals
Generally speaking, exposure does not mean active disease
Lactose Intolerant-
Foods high in calcium but no dairy/milk products
Tracheostomy
Fenestrated (cuffed) tracheostomy
o When capping a fenestrated cuff—deflate the cuff first
80-120 mm
o Hg wall suction pressure

Vasectomy
No permanent effect on sexual function
Should use condom for first 6 weeks post-op V-fib,
defibrillate
You are at risk for developing cervical cancer if you have/had multiple sex
partners
Women who begin menstruating at an early age (such as 9 years old), are at
risk for breast cancer
Absence of menstruation leads to osteoporosis in the patient with anorexia
24 hour urine specimen collection

If a woman starts menstruating during the collection—contact physician
It is not unusual for an adolescent who just started menstruating to not have a
period every month (usually expect to have around 4 in the first year)
Breast buds usually appear between 9-13 years of age—should be investigated if

they appear later
Glucagon (1mg SQ) is given when patient is unconscious with severe

hypoglycemia or those who cannot take PO fluids
*Increases the effects of anticoagulants
Crohn’s Disease
Low fat
Low residue (fiber)
High protein
Priority assessment- respiratory distress

Listen to patient’s breath sounds (most clear assessment)
Femoral angiogram- locate and note the presence of peripheral pulses (easier
to find after the procedure)
Keep leg straight
Check dressing
Increase hydration to excrete dye
Documentation should be specific and factual—
“Vital Signs Stable” is NOT acceptable—what are the vital signs?

Breath Sounds
Asthma
o High-pitched, musical sounds on expiration (wheezing)
Pneumonia
o Soft, high-pitched sounds on inspiration (crackles)
Bronchitis
o Deep, low-pitched rumbling on expiration (rhonchi)
Ileostomy- seen with spinal cord injuries, Crohn’s disease, and to rest the colon
Clean with warm water, dry thoroughly
Appliance should fit snugly around the opening
Should not take laxatives
Can take multi-vitamins
No enteric coated meds or capsules—breakdown in large intestines
Stoma site should be assessed at least once a day
Bags can be changed as needed
Liquid stool
*DO NOT CONFUSE ILEOSTOMY WITH COLOSTOMY*
Maintain bathroom schedule for incontinent patients- every 2 hours
When transferring a patient to another unit—you do not want to bring a

“threat” to the floor—clean vs. dirty patient—risk of infection to a “clean” unit
is not a good choice
For the initial dose of an ACE-Inhibitor—should not give with diuretics and
other medications that can decrease blood pressure (with the initial dose,
hypotension is concern)
Oral fluid intake—1500 mL in 24 hours
Patient who is agitated- reorient to place and time, assign LPN to stay with
patient
In pH regulation, two organs of concern are lungs and kidneys (lungs-

respiratory, kidneys- metabolic)
Esophageal speech- (following a total laryngectomy)- swallows air & eructates

while forming words
(Organ) Transplant patients- require protective isolation following surgery

Most at risk for developing herpes zoster—immunocompromised
Cytomegalovirus- common virus –once infected, virus remains in body for life
*Standard precautions are used—eyewear worn with risk of splash

ARTERIAL BLOOD GASES
*Risk factors for acid-base imbalances include chronic kidney disease and
pulmonary disease
Metabolic Acidosis
Low pH, Low HCO3
Risk Factors
o Type 1 Diabetes (at risk for DKA)
o Salicylate toxicity
o Acute renal failure (decreased production of HCO3)
o Severe diarrhea
o Hyperkalemia
Metabolic Alkalosis
High pH, High HCO3
Risk Factors
o GI losses- vomiting or gastric suctioning or drainage
 Nasogastric suctioning can result in a decrease in acid components
leading to metabolic alkalosis—clients decrease in rate and depth
of ventilation in an attempt to compensate by retaining carbon
dioxide
o Diuretic therapy that leads to sodium and chlorine losses
o Mineralcorticoid excess
o Hypokalemia
Respiratory Acidosis
Low pH, High PaCO2
Risk Factors
o Respiratory depression (decreased respiratory rate)
o COPD and/or asthma
o Inability to ventilate properly (seen in myasthenia gravis, ALS,
muscular dystrophy, and Guillain Barre)
Respiratory Alkalosis
High pH, Low PaCO2
Risk Factors
o Hyperventilation (blowing of CO2)
o Mechanical ventilation
o Any condition that causes
 shortness of breath

From the a** (diarrhea) = metabolic acidosis
From the mouth (vomitus) = metabolic alkalosis
With hyperkalemia- pulse is the first vital sign you check (

due to dysrhythmias)
Diet for Iron-Deficiency Anemia
Oysters, clams, scallops are top-10 sources of iron

Organ meats (red meats), fortified cereals,
dark leafy vegetables, egg yolks
Iron supplements should be taken with orange juice

(Vitamin C) as it facilitates absorption
Take iron elixir with juice or water- never with milk!
Herbal Medications
Potency varies between medications
Considered dietary supplements
Not regulated by FDA
Ma Huang should not be used by patient’s with HTN
Ginkgo – improves cerebral circulation to treat dementia and memory loss--
increases risk of bleeding, increases effects of MAOIs, may reduce
effectiveness of insulin—discontinue 2 weeks prior to surgery, may cause
seizure with overdose
Garlic acts as blood thinner
Black cohosh- used to treat menopause – large doses have been known to
cause seizures, visual disturbances, increased sweating, bradycardia
Feverfew- prevention and treatment of migraines, arthritis, and fever--
should not be taken with coumadin, aspirin, NSAIDS, thrombolytics or
antiplatelet meds—prolongs bleeding
Ginseng- improves strength and stamina—prevents and treats cancer and DM--
it decreases the effects of anitcoagulants and NSAIDS—contraindicated for
women who are pregnant—may increase effectiveness of antidiabetic agents
and insulin
Echinacea- prevents and treats the common cold, stimulates the immune
system, promotes wound healing—may reduce the effects of
immunosuppressants, may increase serum levels of alprazolam, CCB, and
protease inhibitors
St. John’s Wort- depression and anxiety—may reduce the effects of many
medications—theophylline, HIV protease inhibitors, cyclosporine, diltiazem,
and nifedipine – should not be taken with other medications
Patients with hearing loss may exhibit suspiciousness of strangers—results

from interference with communication

Nausea is a concern/priority following eye surgery—risk of increased IOP
*Patient’s undergoing eye surgery should receive flu shot before—can cause
client to sneeze, cough, or blow nose (increasing IOP)

Decreased RBCs/Erythrocytopenia
S/S: fatigue and dyspnea on exertion, pallor, dizziness, malaise, tachycardia
Tetracycline- antibiotic
Causes photosensitivity – wear sunscreen and hat outdoors
Should be taken on an empty stomach
Contraindicated for pregnant women
Sickle Cell Crisis

*Adequate hydration
Dehydration perpetuates cell sickling—should be at least 200cc/hr
Do not give cold packs—further decreases blood flow to area and increases
sickling
DO NOT GIVE DEMEROL (meperidine) TO PATIENTS WITH SICKLE CELL

CRISIS
Phlebitis- reddened area or red streaks at site of catheter
Blanching sign- pressing nail of big toe—indicates circulatory function
Blanching or hyperemia that does not disappear in a short time is a warning

sign of pressure ulcers
Severe to panic level of anxiety- patient is unable to process thoughts and

feelings for problem solving
Priority when managing a physically assaultive client—restore the client’s

self-control and prevent further loss of control
Reward non-attention seeking behaviors by giving client unsolicited attention
Nasogastric Tube
Patient is nauseated and decreased flow of gastric contents—aspirate and
check pH to confirm placement (should be between 0 and 4)
If irrigation is necessary, use normal saline
Intermittent feeding
o Check pH of aspirated contents (normal is pH 0-4)
o Use large barreled syringe to aspirate
o Flush with 30 mL of air before aspiration
History of psych patient should include biopsychosocial data; psychosocial

and physical status are evaluated along with an assessment of the family system
and social support network; evaluation of cognitive ability is important during
physiological status assessment
Patients in seclusion should eat at regular time but remain in seclusion for
client’s safety

Joint legal custody with divorced parents- consent from either parent is
sufficient
Battery is harmful or offensive touching of another person unless court ordered

*For example: Patient refuses medication due to fear that it will poison him
—nurse administers medication IM
Clients have the right to refuse medication even if psychotic
Myelogram
NPO 4-6 hours
History of allergies
Phenothiazines, CNS depressants, and stimulants withheld 48 hours prior
Table will be moved in various positions during test
Post- neuro checks q2-4h, oral analgesics for H/A, encourage PO fluids,
assess for distended bladder, inspect insertion site
Water soluble- HOB raised
Oil soluble- HOB down
Common Signs and Symptoms

Pulmonary TB- low grade afternoon fever
Pneumonia- rusty sputum
Asthma- wheezing on expiration
Emphysema- barrel chest
Kawasaki Syndrome- strawberry tongue. Peeling skin on fingers and toes
Pernicious Anemia- red beefy tongue, pallor, tachycardia
Down Syndrome- protruding tongue
Cholera- rice watery stool
Malaria- stepladder-like fever with chills
Typhoid- rose spots on abdomen
Diphtheria- pseudo membrane formation
Measles- koplik’s spots (clustered white lesions on buccal mucosa)
Systemic Lupus Erythematous- butterfly rash
Liver cirrhosis- spider-like varices
Leprosy- leonine facies (thickened folded facial skin)
Bulimia- chipmunk face (parotid gland swelling), poor dental status
Appendicitis- rebound tenderness, psoas sign (pain from flexing the high
to the hip); Rovsing’s sign (palpation of LLQ elicits pain in RLQ)
Meningitis- Kernig’s sign (knee flex and pain on extension), Brudzinski sign
(neck flex = lower leg flex/bend), nuchal rigidity, photosensitivity
Tetany- hypocalcemia (+) Trousseau’s sign/carpopedal spasm, Chvostek sign
(facial spasm)
Tetanus- risus sardonicus
Pancreatitis- Cullen’s sign (ecchymosis of umbilicus); (+) Grey Turner’s spots

Pyloric Stenosis- olive-like mass, projectile vomiting
Patent Ductus Arteriosus- washing machine-like murmur
Addison’s- bronze-like skin pigmentation (tanned)
Cushing’s- moon face and buffalo hump
Grave’s/Hyperthyroidism- exophthalmos (bulging of the eyes)
Intussusception- sausage shaped mass, Dance sign (empty portion of RLQ),
red currant jelly stools
Multiple Sclerosis- Charcot’s Triad (nystagmus, intention tremor,
scanning speech)
Myasthenia Gravis- descending muscle weakness, ptosis (drooping eyelid)
Guillain Barre- ascending muscle weakness/paralysis
DVT- Homan’s sign
Chicken Pox- vesicular rash (central to distal), dew drop on rose petal
Angina- crushing stabbing pain, relieved by NTG
Myocardial Infarction- crushing stabbing pain- radiates to left
shoulder, neck, arms, unrelieved by NTG
Laryngotrachebronchitis- inspiratory stridor
Transesophageal Fistula- 4 C’s- Coughing, choking, cyanosis,
continuous drooling
Epiglottitis- 3 D’s- drooling, dysphonia, dysphagia (acute emergency)
Hodgkin’s Lymphoma- painless, progressive enlargement of spleen and
lymph tissues, Reedstenberg cells
Infectious Mono- sore throat, cervical lymph adenopathy, fever, fatigue
Parkinson’s- pill-rolling tremors
Cytomegalovirus (CMV) infection- Owl’s eye appearance of cells (huge
nucleus in cells)
Cystic Fibrosis- salty skin, intussuception
Diabetes Mellitus- polyuria, polydipsia, polyphagia
DKA- Kussmaul respirations (deep, rapid RR), acetone breath
Bladder cancer- painless hematuria
Benign Prostatic Hyperplasia- reduced size and force of urine
Retinal Detachment- visual floaters, flashes of light, curtain-like shadow
vision (emergency situation)
Glaucoma- painful vision loss, tunnel/gun barrel/halo vision
o (peripheral vision loss)
Cataract- painless vision loss, opacity of the lens, blurring of the vision,
change in color vision
Retinoblastoma- Cat’s eye reflex (grayish discoloration of pupils)—seen in
photos
Pregnancy Induced Hypertension- proteinuria, HTN, edema
Acromegaly- coarse facial feature
Duchenne’s Muscular Dystrophy- Gower’s sign (use of hands to push one’s
self from the floor)

GERD- heartburn, Barrett’s esophagus (erosion of the lower portion of the
esophageal mucosa)
Hepatic encephalopathy- flapping tremors (asterixis)
Hydrocephalus- Bossing sign (prominent forehead)
Increased ICP- HTN, Bradypnea, Bradycardia (Cushing’s Triad)
Shock- Hypotension, Tachypnea, Tachycardia
Meniere’s Disease- vertigo, tinnitus
Cystitis- burning on urination
Hypocalcemia- (+) Chvostek and Trousseau’s
Ulcerative Colitis- recurrent bloody diarrhea
Lyme’s Disease- Bull’s eye rash
Buerger’s Disease- intermittent claudication (pain at buttocks or legs from
poor circulation resulting in impaired walking)
Hirschsprung’s Disease (Toxic Megacolon)- ribbon-like stool
STIs
Herpes Simplex Type II- painful vesicles on genitalia
Genital Warts- warts 1-2 mm in diameter
Syphillis- painless chancres
Chancroid- painful chancres
Gonorrhea- green, creamy discharges and painful urination
Chlamydia- milky discharge and painful urination
Candidiasis- white, cheesy, odorless vaginal discharges
Trichomoniasis- yellow, itchy, frothy, and foul-smelling vaginal
discharges
CSF Ottorhea- sign of basilar fracture
Battle’s sign and raccoon eyes
NO Nasotracheal suctioning with head injury or skull fracture (increases

ICP)
Tension pneumothorax – trachea shifts to opposite side
Change in color is always a LATE sign

Common Diets
Acute Renal Disease- protein-restricted, high-calorie, fluid-controlled, sodium
and potassium controlled
Addison’s Disease- increased sodium, low potassium diet
ADHD and Bipolar- high-calorie and provide finger foods
Burns- high protein, high calorie, increase in Vitamin C
Bowel Surgery- low residue
Cancer- high-calorie, high-protein
Celiac Disease- gluten-free diet (No BROW- barley, rye, oat, and wheat)
Chronic Renal Disease- protein-restricted, low-sodium, fluid-
restricted, potassium-restricted, phosphorous-restricted
Cirrhosis (stable)- normal protein
Cirrhosis with hepatic insufficiency – restrict protein, fluids, and sodium
Constipation- high-fiber, increased fluids
COPD- soft, high-calorie, low-carbohydrate, high-fat, small frequent
feedings
Cystic Fibrosis- increase in fluids, high-sodium
Diarrhea- liquid, low-fiber, regular, fluid and electrolyte replacement
Gallbladder disease- low-fat, calorie-restricted, regular
Gastritis- low fiber, bland diet
Hepatitis- regular, high-calorie, high-protein
Hyperlipidemias- fat controlled, calorie-restricted
HTN, HF, CAD- low-sodium, calorie restricted, fat-controlled
Kidney Stones- increased fluid intake, calcium-controlled, low oxalate
Nephrotic Syndrome- sodium-restricted, high-calorie,
potassium-restricted
Obesity, overweight- calorie restricted, high fiber
Pancreatitis- low fat, regular, small frequent feedings, tube feeding or TPN
Peptic ulcer- bland diet
Pernicious Anemia (B12)- increase B12, found in high amounts in
shellfish, beef, liver and fish
Sickle Cell Anemia- increase fluids to maintain hydration since sickling
increases when patients become dehydrated
Spinal Cord Injury- high fiber, low fat (prevent constipation and
straining)
Stoke- mechanical, soft, regular, or tube-feeding
Underweight- high-calorie, high protein
Vomiting- fluid and electrolyte replacement
An ill child regresses in behavior
Assessing extraocular eye movements- check cranial nerves 3, 4, & 6
DVT
Goal: promote venous return and decrease in venous pressure
Bed rest with elevated extremity
Stomas
Dusky- poor blood supply

Protruding – prolapsed
Sharp pain + rigidity- peritonitis
Mucus in ileal conduit is expected
Incentive Spirometer- steps: 1) sit upright 2) exhale 3) insert mouthpiece 4)
inhale for 3 seconds and then hold for 10 seconds
MRSA- contact only

VRSA- contact AND airborne (private room, door closed, negative pressure)
Thrombocytopenia- bleeding preacautions

Soft bristled toothbrush
No insertion of anything (suppositories, etc.)
No IM meds as much as possible
Risk of MRSA
Indwelling foley catheter
Receiving medication through port, vascular access device, ET tube
Immunocompromised
Iron deficiency anemia-

Fe PO- give with vitamin C or on an empty stomach
Fe via IM- inferon via Ztrak
Pernicious anemia (B12)- red beefy tongue, will take B12 for life
Meniere’s Disease- restrict sodium, lay on affected ear when in bed, diuretics
to decrease endolymph in cochlea
Triad: vertigo, tinnitus, N/V
Dehiscence of abdominal wound with organ evisceration—elevate HOB to

15 degrees → reduces stress on suture line
*May also be placed supine with hips/knees bent
Gastric ulcer pain- occurs 30 min to 90 min after eating, not at night and does
not go away with food
Pediatric Tips
Intraosseous infusion- in pediatric life-threatening emergencies, when IV
access cannot be obtained, an osseous (bone) needle is hand-drilled into a bone
(usually tibia), where crystalloids, colloids, blood products and drugs can be
administered into the marrow—it is temporary- when venous access is achieved
it is d/c’d
o Only medication that CANNOT be administered IO is
isoproterenol (a beta agonist)
With glomerulonephritis- consider blood pressure to be the most

important assessment paremeter
 Dietary restrictions you can expect- fluids, protein, sodium, and

potassium
In congenital cardiac defects that result in hypoxia- body attempts to

compensate for with an influx in immature RBCs—labs that support this:
increase Hct, Hgb, and RBC count
There is an association between low-set ears and renal anomalies- develop

around the same time (they are also similar in shape)—if a newborn has low-set
ears, this warrants renal function tests
School-age kids (5 and up) are old enough and should have an explanation of
what will happen a week before surgery (such as tonsillectomy)
First sign of pyloric stenosis in a baby is mild vomiting that progresses to

projectile vomiting – later you may be able to palpate a mass, the baby will
seem hungry often, and may spit up after feedings
Kawasaki’s Disease- causes heart problems—coronary artery

aneurysms due to inflammation of blood vessels
A child with a VP shunt will have a small upper-abdominal incision—this is

where the shunt is guided into abdominal cavity-watch for: abdominal
distention → fluid from the ventricles (in brain) will be redirected to abdomen;
watch for signs of increasing ICP→ irritability, bulging fontanels, high-
pitched cry in an infant; lack of appetite and headache in a toddler
o Bed position after shunt placement- FLAT→ do not want the fluid to
shift too rapidly (if signs of increasing ICP are present—elevated HOB
15-30 degrees)
Mechanical ventilation can cause bronchopulmonary dysplasia—other

causes: infection, pneumonia, or conditions that result in inflammation and
scarring
It is essential to maintain nasal patency in a child < 1 year

because they are nose breathers
A child should not be drinking too much milk- it reduces the intake of other
essential nutrients—especially iron (could lead to anemia)
If you can remove the white patches from the mouth of a baby it is
formula- if you can’t it is candidiasis \

MMR and Varicella immunizations come later (15 months)- letters are
later in alphabet
Undescended testis or cryptorchidism is a known risk factor for testicular

cancer- start teaching boys about self testicular exams around 12 – most cases
of testicular cancer occur in adolescence
Stranger anxiety is greatest between 7-9 months

Separation anxiety starts around 4-8 months, peaks in toddlerhood (1-3
years)
For a child exhibiting separation anxiety—offer favorite blanket or toy, talk to

infant when leaving room, allow to hear parent’s voice on telephone
Children frequently set their own pace for development
Mock run through surgery is a great way to prepare a 5 year old
Always report suspected cases of child abuse
Eardrop administration for kids <3 years- pinna down and back
With omphalocele and gastroschisis (herniation of abdominal

contents) dress with loose saline dressing with plastic wrap (non-
adherent)—monitor temperature (lose heat quickly)
After hydrocele repair, provide cold therapy (ice) and scrotal support
NO phenylalanine with positive PKU (no meat, no dairy, no

aspartame/artificial sweetener)
Lofenalac formula
The biggest concern with cold stress and the newborn is respiratory
distress
Normal RR for newborn: 30- 60
Toddlers need to express autonomy (independence)
Theories about bed-wetting relate it to immature bladder and deep sleep

patterns—most children stop bed-wetting by the time they start school
Average circumference of the head ranges from 32-36 cm (increase in size may
indicate hydrocephalus or increased ICP)

Between ages 6 and 12, children grow about 2 inches per year and gain 4.5-
6.5 lbs/year
The incidence of once-common infectious disease such as measles,

chickenpox, and mumps has been most effectively reduced by the
immunization of all school-age children
Exposure to chemicals in the eyes→ irrigate for 20 minutes → another adult,

if present, should call the Poison Control Center and 911
Children have proportionately larger heads that predispose them to head

injuries
Hypoxemia is more likely in children because of their higher oxygen

demand
Liver and spleen injuries are more likely because the thoracic cage of
children offers less protection
Hypothermia is more likely because of children’s thinner skin and

proportionately larger body surface area
Kawasaki disease is the only exception for children taking aspirin
o Important for children’s to receive immunizations
National guidelines indicate that medication dosing for pediatric patients

should be based on the child’s weight (kg)
o Some sources say that BSA is the most accurate method for dosing in
children

Safety- Pediatrics
Infant
Aspiration and suffocation- chop food in fine pieces, appropriate toys, no
plastic bags and balloons (latex balloons are the leading cause of pediatric
choking deaths)
Bodily harm – keep sharp objects out of reach, keep infants away from heavy
objects they can pull down on themselves, do not leave unattended with
animals, monitor for shaken baby syndrome
Burns- check temperature of water, working smoke detectors in home,
handles of pots and pans should be turned to back of stoves, sunscreen
should be used, electrical outlets should be covered, clothing should be flame
retardant
Water heater should be set to no greater than 120 degrees
Drowning- never leave infant unattended near water such as tubs,
toilets, and swimming areas
Falls- never leave unattended, place safety gates on stairs
Poisoning- lock or remove all toxic substances, mediations should be stored
in safety bottles and locked in cupboard, never refer to medication as candy,
poison control number handy
Motor Vehicle Injuries- placed in approved rear-facing car seats in the
backseat- preferably in the middle (away from airbags and side impact)—rear
facing car seats until 2 years of age and they exceed the manufacturer’s
recommended weight (usually 20lbs)
Toddler
Aspiration and suffocation- avoid common causes of choking- hot dogs,
nuts, grapes, peanut butter, raw carrots, tough meat, popcorn, no balloons
or plastic bags, no pillows in cribs, no drawstrings on clothing
Bodily harm- firearms kept in locked boxes, stranger safety
Burns- (same as above)
Drowning- (same as above), taught to swim
Falls- (same as above)
Motor Vehicle Injuries- airbags near the child should be inactivated,
forward-facing until they exceed manufacturer’s weight limit, backseat,
booster seat after they have exceeded weight for forward-facing carseat
Poisoning- avoid exposure to lead paint, safety locks
Preschooler (3 to 6)
Same as above
*Encourage safety equipment (helmet)
School-Age Child (6 to 12)

Bodily harm- firearms should be kept in locked boxes, no trampolines, safe
areas for play, stranger safety, wear helmets
Burns- teach fire safety and potential burn hazards
Drowning- teach to swim
Motor vehicle injuries- younger than 13 should be in back seat, airbags
inactivated
Substance abuse-community resources, family involvement

Adolescent (12 to 20)
Three leading causes of death in adolescents are homicide, suicide, and
o motor vehicle accidents

Potassium is lost when a client is taking a thiazide diuretic – monitor K,
increase dietary K
Should not be taken at night- prevent nocturia
Hypokalemia
ECG changes- ST segment depression, inverted T waves, prominent U
waves—may also experience heart block
Lethargy and muscle weakness
Neck veins are normally distended when patient is supine—veins flatten when
sitting
*Decreased plasma volume→ flattened neck veins when supine
Nurse is not required to explain delegated assignments
Migraines
Fatigue is a trigger
Validation of a nurse having a substance abuse problem does not override

quality client care! Take care of the patient first!
Hemorrhagic shock- PRIORITY→ identify source of bleeding and apply

direct pressure
ECT
NPO after midnight
General anesthesia
Memory loss is an expected outcome
Patients with severe immunodeficiency may be unable to produce an immune

response—as a result, a negative TB skin result does not completely rule out a TB
diagnosis for this patient → chest x-ray and sputum culture will be ordered.
Patients taking immunosuppressive medications are at an increased risk for

development of cancer!

Cultural Considerations
African Americans- many believe that illness is caused by supernatural causes
and seek advice and remedies from faith healers; family oriented; higher
incidence of HTN and obesity; high incidence of lactose intolerance
Arab Americans- may remain silent about health problems such as STIs,
substance abuse and mental illness; if Muslim- many avoid pork and alcohol
Asian Americans- may value ability to endure pain and grief with silent
stoicism; hot/cold, yin/yang, sodium intake is generally high; may prefer to
maintain a comfortable distance; may believe prolonged eye contact is rude
and invasion of privacy
Latino Americans- may view illness as sign of weakness, punishment for
evil doing; family members are typically involved in all aspects of decision
making such as terminal illness
Native Americans- may turn to a medicine man to determine the true cause of
an illness, may value the ability to endure pain or grief with silent stoicism, diet
may be deficient in Vitamin D and calcium due to lactose intolerance, obesity
and diabetes are major concerns
Western Culture- may value technology almost exclusively in the
struggle to conquer diseases; health is understood to be the absence,
minimization or control of disease process
Delegation Tips
DO NOT delegate what you can EAT E-
evaluate (nursing judgment)
A-assess (nursing judgment)
T- teach
Delegate sterile skills to RN or LPN

Where non-skilled care is required, delegate stable client to nursing
assistant
Assign the most critical client to the RN
Clients who are being discharged should have the final assessments and
teaching done by the RN
A new nurse should receive stable patients who require routine care (same
applies to nurses that are transferred to different units for the day)
The LPN can monitor clients with IV therapy, insert urinary catheters,
feeding tubes, and apply restraints
LPN/LVN cannot handle blood
LPN/LVN are given stable patients – can perform sterile procedures on
stable patients
Experienced LPNs can use observation of patients to gather data regarding how
well they perform interventions that have already been taught (including
checking for therapeutic response/adverse effects of medications)
Assisting with ADLs is appropriate for assistive personnel (record I/O too)
Always check for allergies before administering antibiotics (especially
penicillin) – or any medication for that matter!

Neutropenic precautions- no live vaccines, no fresh fruits, no flowers, no sick
visitors, no milk
Any temperature elevation in a neutropenic patient may indicate the
presence of a life-threatening infection
Patients who are neutropenic should be place in a positive-airflow room
In the event of a fire- RACE→ (R) Remove the patient (A) Activate the alarm (C)
Contain the fire by closing the door (E) Extinguish the fire if it can be done safely
Informed consent- patient should know whether other treatment options are
available and should understand what will occur during the preoperative,
intraoperative, and postoperative phases; the risks involved, possible
complications—always allow patient to ask questions!
Veracity is truth and is an essential component to a therapeutic relationship

between a healthcare provider and patient
Beneficence is the action that is done to benefit others
Nonmaleficence is the duty to do no harm
Projection is the unconscious assigning of a thought, feeling, or action to

someone or something else
Sublimation is the channeling of unacceptable impulse into socially acceptable

behavior
Repression is an unconscious defense mechanism whereby unacceptable or

painful thoughts, impulses, memories, or feelings are pushed from the
consciousness or forgotten
People with obsessive-compulsive disorder realize that their behavior is

unreasonable, but are powerless to control it
Hypervigilance and déjà vu are signs of PTSD
Health Screening for Cancer

CAUTION
C- change in bowel or bladder habits
o a sore that does not heal
U- unusual bleeding or discharge
T- thickening or lump in breast or elsewhere
indigestion or difficulty swallowing
O- obvious change in a wart or mole
N- nagging cough or hoarseness

Common sites for metastasis- liver, brain, lung, bone, lymph
When a cancer patient is receiving radiation- main concern is preventing

infection because radiation causes leukopenia
Radioactive Iodine- want to flush it out of body → increase fluid intake for 2
days (3-4 liters unless otherwise contraindicated)—flush the toilet twice after
using
*Limit contact with patient to 30 min/day
NO PREGNANT VISITORS/NURSES and no kids
The main hypersensitivity reaction seen with antiplatelet drugs is

bronchospasm (anaphylaxis)
Ex: clopidogrel, aspirin
Do not fall for the “reestablishing a normal bowel pattern” as a priority with
small bowel obstruction—the patient can’t take in oral fluids, “maintaining fluid
balance” comes first!
Basophils release histamine during an allergic reaction
Other than to initially test tolerance- G tube and J tube feedings are usually
given as continuous feedings
Tamoxifen (chemotherapy agent) can cause visual changes—can be irreversible

—assess visual acuity throughout treatment
You should ask every new admission if he/she has an advance directive
Succinylcholine Chloride (Anectine)- used for short-term neuromuscular

blocking agents for procedures like intubation and ECT
Typical adverse reactions to oral hypoglycemic- rash and photosensitivity
Hypotension may alter the accuracy of O2 sats
An antacid should be given to a mechanically ventilated patient with NG tube if

the pH of the aspirate is <5.0—aspirate should be checked at least q12h
Ambient air (room air) contains 21% oxygen
Normal PCWP (pulmonary capillary wedge pressure) is 8-13 → readings of 18-

20 are considered high

High potassium (hyperkalemia) is expected with carbon dioxide narcosis
(hydrogen floods the cell, forcing potassium out)- carbon dioxide narcosis causes
increased ICP
An NG Tube can be irrigated with cola and should be taught to the family
when a client is going home with the tube
If your normally lucid patient starts seeing bugs, check respiratory status FIRST
—the first sign of hypoxia is restlessness, followed by agitation (continues to
decline from there) → leads to delirium and hallucinations, and eventually
coma!
o Check O2 stat
o ABGs if possible
Status epilepticus – most important assessment is level of consciousness
Pneumonia may manifest itself as mental confusion due to hypoxia
Can’t cough → ineffective airway clearance
If a patient has low Hgb/Hct—should be evaluated for signs of bleeding

(dark/black stools)
A patient with liver cirrhosis and edema may ambulate, then sit with legs
elevated to try to mobilize the edema
Safety over nutrition in a severely depressed patient
Depression can manifest itself in somatic ways- such as psychomotor

retardation, GI complaints and pain
Prolonged hypoxemia is a likely cause of cardiac arrest in a child
Coarctation of the aorta causes increased blood flow and bounding pulses
in the arms
Newly diagnosed HTN- assess BP in both

arms
Gonorrhea is a reportable disease!

Stairway to Heaven (Crutches)
The good go to heaven- good leg goes up the stairs first with crutches
(crutches move with the affected leg)
The bad to to hell (down)- bad leg goes down the stairs first (crutches move
with the affected leg)
Place a wheelchair parallel to the bed on the strong side
Vasopressin- “press in” → vasoconstriction (used when patient is hypotensive)
Burning sensation in the mouth and brassy taste are adverse reactions to Lugol
Solution (iodine) – used in treatment of hyperthyroidism
Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure
When the oxygen flow rate is higher than 4L/min, the mucous membranes can
be dried out- the best treatment is to add humidification to the oxygen
delivery system (applying water-soluble jelly to the nares can also help decrease
mucosal irritation)
A nonrebreather mask can delivery nearly 100% oxygen—when the patient’s

oxygenation status does not improve adequately in response to delivery of
oxygen at this high concentration, refractory hypoxemia is present—usually at
this stage, the patient is working very hard to breathe and may go into
respiratory arrest unless healthcare providers intervene by providing
intubation and mechanical ventilation
The endotracheal tube should be marked at the level where it touches the
incisor tooth or nares—this mark is used to verify that the tube has not shifted
Infections are always a threat for the patient receiving mechanical ventilation
—elevated temperature is cause for concern
Confusion in a patient taking enoxaparin (Lovenox) could indicate intracerebral

bleeding!
Removing large quantities of fluid from the pleural space can cause fluid to shift
from the circulation into the pleural space, causing hypotension and tachycardia
—may need IV fluids to correct this
Low sodium diet is 2g or less
Persistent and irritating cough (dry cough caused by accumulation of

bradykinin) is a possible adverse effect of ACE-inhibitors (enalapril) and is a
common reason for changing to another medication category such as ARBs

The goal when treating HTN with medication is reduction of blood pressure to
under 140/90

Because continuous chest pain lasting more than 12 hours indicates that
reversible myocardial injury has progressed to irreversible myocardial necrosis,
fibrinolytic drugs (TPA) are not recommended for clients with chest pain that
has lasted for more than 12 hours
The goal in pain management for the client with an acute MI is to

completely eliminate the pain. Even pain rated at a level of 1 out of 10 should
be treated with additional morphine sulfate
Hyperkalemia is a common adverse effect of both ACE inhibitors and

potassium-sparing diuretics
Proton pump inhibitors (omeprazole) affect the metabolism of clopidogrel

and decrease its effectiveness
The most common complication after coronary arteriography is hemorrhage—

earliest indication of hemorrhage is an increase in heart rate
PVCs occurring in the setting of acute MI can lead to ventricular

tachycardia and/or v-fib (cardiac arrest), so rapid treatment is necessary
Anticoagulant medications are high-alert meds and require special

safeguards- such as double-checking medication by two nurses before
administration
B-type natriuretic peptide levels increase in clients with poor left ventricular
function and symptomatic heart failure and can be used to differentiate HF from
other causes of dyspnea and fatigue (such as pneumonia)
A patient with thrombocytopenia (low PLT count) should not take aspirin
routinely—aspirin decreases platelet aggregation
When a hemophiliac patient is at high risk for bleeding, the priority

intervention is to maximize the availability of clotting factors (administer Factor
VII)
Hemophilia is x-linked – mother passes to son
Joint pain in hemophilia indicates bleeding—treatment includes factor VII and

RICE
Bence Jones proteins in the urine indicate multiple myeloma
Increased risk of infection after splenectomy—monitor for elevation of

temperature
Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially

serious consequence of chemotherapy in acute leukemia

A non-tender lump or swelling near lymph nodes may indicate that the patient
has developed lymphoma (possible adverse effect of immunosuppressive
therapy
A newly-admitted patient needs to be assessed as soon as possible—if all

patients are stable, the new admission takes priority because plan of care needs
to be completed

Order of a newborn bath:
Place on warm surface
Cleanse eyes
Cleanse face
Cleanse body with warm water
Wrap infant in pre-warmed blanket
Shampoo head/hair
If TPN is not ready when it is due, D10W or D20W should be administered

Always check the order before administering TPN—generally each bag is
individually prepared by the pharmacist
Solution should not be cloudy or turbid
Prime the tubing and thread the pump
To prevent infection, scrub the hub and use aseptic technique when inserting
the connector into the injection cap and connecting the tubing to the central
line
Set the pump at the prescribed rate
Probiotic therapy- live microorganisms similar to those found in GI track

—when colonized they enhance the immune response and stabilize the
mucosal barrier in the digestive track
Patients who may benefit:
o Antibiotic associated diarrhea
o IBS
o Lactose intolerance
(+) nitrite in urine is indication of UTI

Other signs: elevated WBC count, elevated temp, confusion in elderly,
burning with urination
3-minute hand scrub is particular to the newborn nursery area and included in
medical asepsis
Medical asepsis = clean technique
Two identifiers must be used when administering medication

Name on bracelet
Photo
Bar code system
Asking patient to state name
Time Out”
Called before the initiation of any surgical procedure
Patient can be involved
Goals
o Correctly identify the patient
o Correctly identify the site and side
o Verify that OR team agrees on procedure

Oculogyric crisis- eyes locked upward (acute dystonic reaction from
antipsychotic medications)—contact physician- anticipate administration of
anticholinergic medication- benztropine (cogentin)
Talipes equinovarus- club foot
The priority for migraine headache is pain management
A client with a seizure disorder should not take OTC medications without
consulting with the health care provider first
First priority for the client with a spinal cord injury is assessing
respiratory patterns and ensuring an adequate airway
Priority intervention for a client with Guillain Barre Syndrome is

maintaining adequate respiratory function—clients with Guillain Barre
are at risk for respiratory failure, which requires urgent intervention
Clients with right cerebral hemisphere stoke often manifest neglect

syndrome—lean to the left, when asked, respond that they believe they are
sitting up straight—often neglect the left side of their bodies and ignore food
on the left side of their food trays
Bacterial meningitis is a medical emergency- antibiotics are the priority

medication (cultures and specimens should be drawn before)
Priority action during a generalized tonic-clonic seizure is to protect the

airway by turning the client to one side—oxygen is used in postictal phase
Exophthalmos- instill artificial tears (hyperthyroidism- Graves) Bulge
test confirms presence of fluid in knee- leg should be extended Side
rails should always be elevated for disoriented patients
Bismuth subsalicylate absorbs PO meds and should be administered

separately
Normal CVP- 3-12 mmHg (cm of water)
Early signs of hepatic encephalopathy

Impaired thought process
Insomnia and sleep disturbances
Tremors
Sengstaken-Blakemore tube- have scissors at bedside (airway obstruction→

cut balloon with scissors)

Nurse is obligated to share client information with personnel directly involved in
care
Bowel perforation requires emergency surgery (result of increased

intraluminal pressure)—intestinal contents are released into peritoneum leading
to peritonitis
Heat in cast is a sign of pressure, which can indication poor circulation! Requires
fast assessment!
Hypotonic (0.45% NS) shifts fluid into intracellular space
Radium implant- strict bed rest (so no, they cannot use a bedside commode)
Cyclophosphamide – will likely cause alopecia 4-5 weeks after starting
Bell’s Palsy- use artificial tears (4x/day)
Cocaine Abuse S/S

Insomnia
Rhinorrhea
Tachycardia
Euphoria
*Cocaine is a stimulant
Low titer means risk for developing disease
Breathing slowly will enhance relaxation of abdominal muscles
Shingles- able to care for non-high risk clients—cover lesions

Should not care for pregnant women, premature infants,
immunocompromised
Parenteral Nutrition (PN)- monitor serum glucose and electrolytes

Most common complication involves fluid and electrolytes No
Beta-Blockers with COPD
No lidocaine with heart blocks→ diminishes existing ventricular response
Causes of tinnitus
Aspirin
Diuretics
Neurological conditions
Loud noises
Impacted earwax or foreign bodies in the ear
Ear infections
A bulging red or blue tympanic membrane is a possible sign of otitis media or

perforation

Vertigo without hearing loss should be further assessed for nonvestibular
causes, such as cardiovascular or metabolic problems!

Stapedectomy (surgical procedure of the middle ear; used for hearing loss
related to otosclerosis)
Heavy lifting should be avoided for at least 3 weeks after the procedure
Water in the ear, and air travel should be avoided for at least 1 week
Coughing and sneezing should be performed with the mouth open to
prevent increase pressure in the ear
Ear Irrigation
Use an otoscope to assess the ear first
Fill syringe with warm fluid
Angle the syringe to allow the fluid to flow along the side of the ear canal, not
directly at the eardrum
Flush with continuous pressure, rather than a pumping action
You should see fluid return with cerumen
If not, wait at least 10 minutes and repeat
Tipping the head allows gravity drainage of fluid left in the ear canal
Basilar invagination (platybasia) causes brainstem manifestations- can be life

threatening
4 C’s of Communication
Clear
Concise
Correct
Complete
*Ensures the staff understands what is being said
Postoperative pain and numbness occur for a longer period of time with
endoscopic carpal tunnel release than with an open procedure.
o Hand movements, including heavy lifting, may be restricted for 4-6 weeks
after surgery
o Patients experience discomfort for weeks to months
o Surgery is not always a cure
o In some cases CTS may recur months to years after surgery
Fat embolism syndrome is a serious complication that often results from

fractures of long bones—its earliest manifestation is altered mental status
caused by a low arterial oxygen level

The goal of bowel training is to establish a pattern that mimics normal
defecation, and many people have the urge to defecate after a meal
Refeeding syndrome occurs when aggressive and rapid feeding results in fluid
retention and heart failure—monitor for signs of fluid volume overload
Substance abuse may exclude a person from the transplant list
The presence of glucose in the nasal drainage indicates the fluid is CSF
(cerebrospinal fluid) and suggests a CSF leak
Vitiligo, or patchy areas of pigment loss with increased pigmentation at

the edges, is seen with primary hypofunction of the adrenal glands and
is caused by autoimmune destruction of melanocytes in the skin
Silver scaling on skin is associated with psoriasis
Wounds should be debrided before obtaining wound specimen for culturing
Isotretinoin – oral medication used for acne—has high incidence of birth

defects—important to stop using medication at least a month before attempting
to become pregnant
Wheals (on the skin) are frequently associated with allergic reactions—asking
the patient about exposure to new medications is the most appropriate question
Chemical/toxic exposure to skin→ priority is to remove the chemical from

contact with the skin to prevent ongoing damage
Prostate disease increases the risk of UTIs in men because of urinary
retention A cystoscopy is needed to accurately diagnose interstitial cystitis
A patient with urge incontinence can be taught to control the bladder as long
as the patient is alert, aware, and able to resist the urge to urinate by starting
a schedule for voiding, then increasing intervals between voids
Women should avoid irritating substances such as bubble baths, nylon

underwear, and scented toilet paper to prevent UTIs
Bruising is expected post-lithotripsy and can be quite extensive
A patient with only one kidney should avoid all contact sports and high-risk
activities to protect the remaining kidney from injury and preserve kidney
function
During the oliguric phase of acute kidney failure, a patient’s urine output is
greatly reduced. Fluid boluses and diuretics do not work well. This phase

usually lasts from 8-15 days

Patients with acute kidney failure usually go through a diuretic phase 2 to 6
weeks after the oliguric phase—the diuresis can result in an output of up to
10L/day of dilute urine→ during this time it is important to monitor for
electrolyte and fluid imbalances
MAP = [ (2 x diastolic) + systolic ] divided by 3
A palpable bladder and restlessness are indicators of urinary retention, which

requires action to empty the bladder (such as catheterization)
Benign prostatic hyperplasia (BPH)

o Client will have trouble starting a urinary stream
o Elevated level of prostate-specific antigen
Irregularly shaped and nontender lumps are consistent with a diagnosis of

breast cancer
Transurethral Resection of the Prostate (TURP)

o Bladder spasms may indicate that clots are obstructing the catheter,
which would indicate the need for irrigation of the catheter with 30 to 50
mL of NS using a piston syringe (irrigation would be first action)
o Hemorrhage is a major complication following a TURP—signs would be
catheter draining deep red blood
Tamulosin- used to treat BPH -- monitor for orthostatic hypotension

o Improves symptoms by relaxing the muscles in the prostate and bladder
neck—making it easier to urinate
o Force of urinary stream may increase
Testicular Torsion
o Scrotal swelling and severe pain—likely not relieved or decreased
by elevation of the scrotum
o Emergency situation that requires immediate assessment and
intervention because it can lead to testicular ischemia and necrosis
within a few others
Sildenafil (Viagara)- potent vasodilator used in the treatment of erectile

dysfunction
o Has caused cardiac arrest in clients who were also taking nitrates such
as nitroglycerin
After an A&P repair (vaginal wall repair/anterior and posterior), it is essential

that the bladder be empty to avoid putting pressure on the suture lines
o Abdominal firmness and tenderness indicate that the bladder is
distended—requires catheterization
Rapid Response Team (RRT)

o Role of RRT is the immediate assessment and stabilization of a client

First-degree relatives of patients with the BRCA gene should be screened
annually with both mammography and MRI
Severe spontaneous hemorrhage is not expected until the platelet count drops
below 20,000 mm3
Frequent swallowing following T&A may indicate bleeding
Tracheal deviation suggests tension pneumothorax- priority situation→

requires chest tube
Synthetic surfactant improves respiratory status and decreases the incidence

of pneumothorax in premature infants with respiratory distress syndrome (RDS)
Crackles throughout both lungs indicate that a child has severe left ventricular
failure as a complication of endocarditis
Decreased responsiveness in a patient with a clotting disorder may indicate

intracerebral bleeding—priority situation
Chlamydia is the most prevalent STI in the US—screening is strongly

recommended for all sexually active females 25 years or younger
Iron is a toxic substance that can lead to massive hemorrhage, coma, shock,
and hepatic failure—deferoxamine is an antidote that can be used for severe
cases of iron poisoning
Triage requires at least one experienced RN
Primary survey for a trauma patient arriving to ED includes a brief neurologic

assessment to determine level of consciousness and pupil reaction
Secondary survey includes measuring vital signs, assessing the abdomen, and
checking pulse oximetry readings
Heat stroke is a medical emergency that increases the risk for brain damage
You respond to a call for help from the ED waiting room—an elderly client is lying
on the floor….
o Establish responsiveness first (the client may have fallen and sustained
a minor injury)
o If the client is unresponsive, get help and activate the code team
o Performing the chin lift or jaw thrust maneuver opens the airway
o The nurse is then responsible for starting CPR
CPR should not be interrupted until the client recovers or it is determined
that all heroic efforts have been exhausted
o A crash cart should be at the site when the code team arrives—
however, basic CPR can be effectively performed until the team is
present

Pulsating mass in abdomen indicates abdominal aneurysm—concern is rupture
A person who experienced a threat to his or her own life is at the greatest risk for
psychiatric problems following a disaster incident (such as PTSD)

Appropriate in Disaster Triage
o Check airway, breathing, circulation
o Assess the level of consciousness
o Visually inspect for gross deformities, bleeding, and obvious injuries
o Note color, presence of moisture, and temperature of the skin
o Check vital signs, including pulse and respirations
Patients with conversion disorders are experiencing symptoms, even though

there is no identifiable organic causes→ therefore they should be assisted in
learning ways to cope and live with the disability
Family history of completed suicide is a risk factor for an individual committing

suicide
Before someone enters an alcohol rehabilitation program, there should be a

medically-supervised detoxification
When delegating psychiatric patients to new RNs, try to avoid assigning a

psychotic patient – they can be very threatening to new RNs
Restraints must be tied to a stationary portion of the bed using quick-release

knots→ distal pulses should be checked
o Restraints are rarely a planned event
Take time for yourself—a mind that is fried, is not a good use of
time


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How to tackle- WHO DO YOU SEE FIRST- questions:

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Chicken pox can be rapidly transmitted to other clients—should be isolated

*Private room or cohort, mask (door open, 3ft distance)

Current CDC evidence-based guidelines indicate that droplet precautions

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Impetigo- caused by Staph and Strep, untreated can cause acute

Order of PPE Application

Order of PPE Removal (Alphabetical like Dictionary)

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Individuals who have contact with infants should be immunized against

The ventilator bundle developed by the Institute for Healthcare Improvement

No pee, no K (do not give potassium without adequate urine output)

ElVate Veins, dAngle Arteries for better perfusion

*IV push should be given over 2 minutes*

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Air Embolism- (S/S: chest pain, difficulty breathing, tachycardia,

Pulmonary Embolism- (S/S: chest pain, difficulty breathing, tachycardia,

Women in Labor with non-reassuring FHR-

Tube Feeding w/ Decreased LOC

During Epidural/Lumbar Puncture

Post Lumbar Puncture (LP) – (and also oil-based myelogram)

Patient with Heat Stroke

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During Continuous Bladder Irrigation (CBI)- catheter is taped to thigh

Post Cataract Surgery

Infant with Spina Bifida

Buck’s Traction (skin traction)

Post Total Hip Replacement

Cord Compression/Prolapsed Cord

Vena Cava Syndrome (pregnant women)

Infant with Cleft Lip

Infant with Cleft Palate

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Above Knee Amputation

Below Knee Amputation

After Supratentorial Surgery (suture behind hairline)

After Intratentorial Surgery (incision at nape of neck)

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Spinal Cord Injury

Peritoneal Dialysis when Outflow is Inadequate

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Liver biopsy- (prior) administer Vitamin K, NPO at midnight, teach patient

Morphine is contraindicated in pancreatitis—it causes spasm of the Sphincter

*With chronic pancreatitis, pancreatic enzymes are given with meals

Diabetes Mellitus- pancreatic disorder resulting in insufficient or lack of

o Type II (insulin resistant)- beta cells do not produce enough insulin or

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Repaglinide is a meglitinide analog drug—short-acting agents used to prevent

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Hypoglycemia requires urgent treatment

IV push should be given over 2 minutes